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FOR OFFICE USE: APPLICATION A *or Non-Transferable, Revocable,Suspendabl* PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San`Joaquin County Ordin nc o. 1862 and the Jules and regulations of the San oaquin Local He i7`_�+�yralth Distri t. Exact Site Address_ ./�f igt�/✓J �-. e�nct/v a ity/Town " 1.20 Owner's Namele Phone Address City Contractor's Name _ License n�9Dd/3 Business Phone Contractor's Address � 5-a,`� ��?�O� �.y�`�7�__Ol� ? ? Prgency Phone c53rS=6627/ .J Is Certificate of Workman's CompensationIns ranee on File With SJLHD? Yes x No d TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ r DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field ,(rg!i f Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1160Gva ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION 9 ROTARY Type of Grout ��ccR�TZL-sL/f•>[t ❑ DISPOSAL ❑ OTHER Other Information `xr4sJ(4 ❑ GEOPHYSICAL Surface Seal Installed By: ( c:tc4z&f� PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done fn PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth (I,J Describe Material and Procedure -4k 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 the work 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-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." Iwill all for a Grout Insp on prior to grouting and a final inspection. 9 Signed X A (/ Title: Date: 17 (Drao4lct Plan on Reversetide) FOR DEPARTMENT USE ONLY PHASE I / Application Accepted B Date Additional Comments: - hase I Grout Inspection t4� �7PJhase 111 Final Inspection Inspection 11By Date1:1 ( "��n�,--,R/ Inspection By �-y` Date : _.. Fee Is Due: ANNUALLY ❑ PER UNIT PER SITE EACH ❑ January 1 6 Received By January 31 ❑ July 1 8 Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHIEfIll ceived by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201