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=¢ Applications Will Be Processed When Submitted Properly Completed-Be Sure To Sign The Appucauo`. APPLICATION fuel bri"ICt= - (For Non-Transferable,Revocable,Suspendable) PUMP&WELL __- ENVIRONMENTAL HEALTH PERMIT I WATER QUALITY (COMPLETE IN TRIPLICATE) # Application is hereby madetotheSan Joaquiti Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with JoaquinCoun� tY Ord'nance Not 1862 and the r les and regulations of the Sa fquin� I Health District Exact Site Address t ' � �� " City/Town p Owner's Name ill� �--��- Phone Address /_6_7_1--3�--A41 < �- -" - Contractor's Named License# Business Phone �� - -�-- Contractor's AddressEmergency Phone � � --- - --� Is Certificate of Workman's Compensation Insura ce on File With SJLHD? Yes L No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION 13 WELL ABANDONMENT 13OTHER C1 PUMP INSTALLATION❑ PUMP REPAIR 13 REPLACEMENTigr DISTANCE TO NEAREST: Septic Tank Sewer Lines _ -- Pit Privy S Cesspool/ eepage Pit Other _ Sewage Disposal Field field� _ t Property Line.7S! Private Domestic Well Public Domestic Well_ -- ` INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - - e'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -- ❑ DOMESTIC/PUBLIC -1 DRIVEN Gauge of Casing - ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal lr ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information - [' ❑ GEOPHYSICAL Surface Seal Installed By: -- �I PUMP INSTALLATION: Contractors — r. Type of Pump— -- __�H�,P�. /mss --- PUMP REPLACEMENT- [&State Work Done ,,,,,,"""""'"""��J e- ��__F_ —�=�'fir" � �' 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. 1 Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework for which this perrrti 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:"I 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." k I will call for a Grout Inspection r to grouting nd a final inspe n• / p, Title: _- Date: Signed X ! ' (Draw Plot Plan an Reverse Side) / FOR :,D_[EPfAR.TIMENT USE ONLY t PHASE I �`� Date Application Accepted By . 1 Additional Comments: - -- Phase it Grout inspection has 1 Final Inspectio n I inspection 8y - - Date Inspection B Date `r Fee Is Due: 'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 fl eceived By.lanuary 3t ❑ July 1&Received EMITBy U y 31 BILLING I REMITTANCE S AMOUNT DUE CHECKED BASE PLANATION DATE DATE REMITTED AMOUNT 1 FEE z4v _ LESS PRORATION — - - - -- - f PLUS — - PENALTY i OTHER OTHER 4 Received by- Dale Receipt No. Permit No. ' I uance ate Mailed Delivered t •1601 E.HAZELTON AVE.,P.O.Bow 2009 $TOCKTON,CA 9520 DJ �, APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMITISERVICES