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catlbit 1dPBi6i`Pr4ce&d Submitted Properly Completed. Be SureToSignTheApplication.7iE FOR OFFICE USE: APPLICATION NOV6' 198OFor Non-Transferable, Revocable, Suspendable) k PUMP&WELL ENVIRONMENTAL HEALTH PERMIT SAN .10AQ1 fl IN LOICAL (COMPLETE iN TRIPLICAT -/� T�{ DIST R=tt(� WATER QUALITY %7F%, N L[�_ r"= a Application is hereby made to the San Joaquln�ocal Ialth District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joagyin Local Health District, Exact Site Address_ 3�.i►'t I. Na, o F /Ul�o4 City/Town 4/_ i WR 11 Rd- OD D`11 Ttp-3Z Owner's Name Phone Addressz E City Contractor's Name �pCY.IBnee Drillers Drilling Corp. License#3 7792-✓ Business Phone 1731—. �P F Contractor's Address 9• Emergency Phone I� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_lel_� No TYPE OF WORK (CHECK): NEW WELL.13 DEEPEN ❑ RECONDITIONX DESTRUCTION❑ vv WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 I` REPLACEMENT❑ �T I� DISTANCE TO NEAREST: Septic Tank /✓7 i Sewer Lines Pit Privy II Sewage Disposal Field Cesspool/Seepage Pit Other— Property ther Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL g�i N ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation ® DOMESTIC/PRIVATE DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY i Type of Grout _ II ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: k -�1€ PUMP INSTALLATION: Contractor - ! =c Type of Pump $ 'A H.P. PUMP REPLACEMENT: ❑ State Work Done r PUMP REPAIR: ❑ State Work Done H ! DESTRUCTION OF WELL: Well Diameter Approximate Depth � r i Des cribe.,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. I` - Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall not employ any person in such manner as to become subject to Workman's compensation laws of California.'ij 4 Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this C_ - § permit is issued, I shall employ persons subject to workman's compensation laws of California." 'I will call for a Gro nspection prior to groutingtand a final inspection. .r Signed X r Title: Date: Noll, -SI (Draw Plot Plan on Reverse Side) r _ FOR DEPARTMENT USE ONLY PHASE l L.J17� Date Application Accepted By Additional Comments: 'Phase 11 Grout Inspection Pose Final nspection ection B ' Date �~S Inspection 8y�r�v Date y Y Insp pp Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 F1 July 1 &Received BylfJuly 31 REMIT BILLING f BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT ETU i FEE .j LESS I! PRORATION - •ih PLUS PENALTY } OTHER li OTHER h 07 Received by Date Receipt No, Permit No. I suanc Date Mailed Delivered ik APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Sox 2009 STOCKTON,CA 95201