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.P y Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y FOR OFFICE USE: APPLICATION REMITTED —� (For Non -Transferable, Revocable, Suspendable) PUMP & WELL HEALTH PERMIT h Ea u� rN-i QV4 ENVIRONMENTAL • 0 (COMPLETE IN TRIPLICATE) WATER QUALITY j AppliEation is hereby made to the San Joaquin Local Health District fora permit to construct and; or install the work herein described. This application is made in compliance with San Joa uin County Ordi an No. 18 a the.rules and regulations of the San Joaquin Lpc I Health District. _Z2 r d City/Town _ Exact Site Address 6 649JU S Phone OwnersName xQ tAJ4& Address Contractor's Name City cense #.� 2-ZI/ Business Phone— Contractor's Address % Emergency Phone Insurance File With SJLHD? Yes No J Is Certificate of Workman's Compensation on TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR ❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank �_� Serer Lines �t� ( Pit Privy Pit Other Sewage Disposal Field _/0,0 f Cesspool/Seepage Property Line /t> if— Private Domestic Well - Public Domestic Well -- ----- INTENDED USE TYPE OF WELL /r ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well ExcavationAl DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 4 ❑ IRRIGATION - GRAVEL PACK Depth of Grout Seal ► ❑ CATHODIC PROTECTION XrROTARY Type of Grout C S- a.,� `` ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: ,,12,- e PUMP INSTALLATION: Contractor Type of Pump H. P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter—. Approximate Depth Describe Material and Procedure _.I hereby certify that I have prepared this application and that the work will be done .in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of thework for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's Compensation laws of California." Contractor's hiring or sub-contractin ignat.re certifies the following: "I certify that in the performance of the work for which this y permit is issued, I hall mpioy per ns subject to workman's compensation laws of California." I I for a ut pecti routing and a final inspection. Signed X Title: Date: 8 en E (Draw Plot Plan on Rever Side) PHASE Application Accepted By Additional Comments:— Phase 11 -Grout Inspection Z 74 o inspection By Date, f FO DEPARTMENT USE Oe Date w e'f .. Phase 111 Final Inspection Inspection By _ Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 FEE I LESS PRORATION PLUS ` PENALTY L OTHER BASE 1 EXPLANATION 4 ) APPLICANT—RETURN ALL COPIES TO: BILLING •REMITTANCE DATE I DATE n,, ar In�tQ" �Lv v .ceived By January 31 ❑ July 1 & Received By July 31 QJ -7 J y � } b�k )' `i�`+ta— `a` 1� JfiL ` -7(p � '� pirNJ r+ P' l e , Q Uva VN Receipt, Permit No fswanc6 Date Mailed Delivered ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON. CA 95201 REMIT i AMOUNT DUE CHECKED REMITTED AMOUNT Ea u� rN-i QV4 4 QJ -7 J y � } b�k )' `i�`+ta— `a` 1� JfiL ` -7(p � '� pirNJ r+ P' l e , Q Uva VN Receipt, Permit No fswanc6 Date Mailed Delivered ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON. CA 95201