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+ � - Applications Will Se Processed When Submitted PropedY Completed.tie aure r v-V.. •••�err••- ••-- FOR OFFIC VSE: APPLICATION (For Non-Traniferable,'Revocable,Suspendable) 1 PUMP&WELL c p ENVIRONMENTAL HEALTH PERMIT 1Cie/ WA p UA11TY. .,. , , o` - /400- (COMPLETE IN TRIPLICATE) t.2.G l.ID& S, pr4•r1's�.Ljos� „.�i4S� � }'' O' AppliPLETcation isNTRI madetotheSahJoaquinLocatHealthDistrictforaper I toconstructand/or�nstaflthevrorkhereindescribe .This application is made in compliance with San Joaquin County Ordinance 0.1 2 e d the- made he y�1es and r 9 lation y i the San J aqu C c Health District ' 11 ,� �►r p J�t��' I Clt /Town - I Exact Site Address �.rn � e> Phone" ' r Owner's Name it �'�:, s .'�,+ :p :' gar.' .:! ;.•at 'City Address •'T Z 7 r �: ' '. License ' !L :' Busiriess'Phorae •:,� Contractor's Name_ — r••=-;y, -. sErsiergency Ph ne Contractor's Address No Is Certificate of Workman's Compensation ins.rance on File With SJLHD? Yes-; TYPE OF WORK{CHECK): ' NEW WELL DEEPEN•❑ •' REO, NDiTION❑ `� DESTRUCTION WELL CHLORINATION 13 WELL ABANDONMENT 13 OTHER NPUMP INSTALLATION 13 PUMP REPAIR❑ REPLACEMENT❑ I �. ' •--�— Sewer Lines �- Pit Privy —� DISTANCE TO NEAREST: Septic Tank Sewage Disposal Field �-- CesspoollSsepage Pit Other_ �-� Private DomesticWel. Public Domestic Well '�-- Property Line Domestic'Well � f f C INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation ❑ DRILLED Die.of Wei1 Casing ' DOMESTIC/PRIVATE .. + ..... ((�❑ DOMESTIC/PUBLIC ❑ DRIVEN ` Gaug�e of Casing j 13 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal_ , ❑ CATHODIC PROTECTIONROTARV Type of Grout + i, ❑ OTHER ' Other Information (� 13 DISPOSAL . .� Surface Seal Installed ,y: I ❑ GEOPHYSICAL I PUMP INSTALLATION: Contractor Q HP TYpe.of Pump 5, 5, PUMP REPLACEMENT: ❑ State Work Done i L PUMP REPAIR: ❑.,State Work Done fie+ DESTRUCTION OF WELL: Well Diametet Approximate Depth Describe Material and Procedure k t - - I hereby certify that have prepared t iis'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 theworkforwhich this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's,compensation laws of California." Co6tractoes hiring orsub-contracting signature certifies the following."i certify that in the performance of the work for which this permit is issued, I shill employ persons subject to workman's compensation laws of California.'.. I will call for a Grout;lnspection prior to grouting and a final inspection. 1i'- ' - t ' Date: Signed X _ Title: (Draw Plot Plan on Reverse Side) I `i y FOR DEPARTMENT USE.ONIY _ ti. PHASE 1 - i Date Application Accepted By•5 sTtl° T Additional Comments:.` `' Phase rarout-Inspection'"' r Phase Hl Mal Inspection r - .« �: • ;Datkip r In pection By ..-.Date_ fanspection By % �^ �/.�y �jr Fee IS Due'❑ ANNUAL ., 'PER'UNIT ❑ EACH• LI January l 8 eceived By'January 37" ❑July t &Recervetl 8y July 3'I REMIT q 2i BILLING REMITTANCE S AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT FEE LESS I " PRORATION _ PLUS PENALTY OTHER _ OTHER _ •- y Received by pate .—Receipt-No.' ..r_ Permit No. – •- Issuane Date Mailed Delivered APPLICANT—RETURN ALL COPIE9 TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 7601 E.HA2ELTONAVE.,P.O.Bol.2009 9TOCKTON,CA 95201 n