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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY � �$J• Application is hereby made to he San Joaquin Local Health District fora permit inS�Ydllltie`,nork� P e e n described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sari i�J,,o�aqu,�iin��L�gcal Health District. � Exact Site Address .-_ G L/ f�1��/L! L,( City/Town — 7 1 '7 0/-` t17 Owner's Name . CAI L,-'IV Phone fes/ — /_ -7 Address S46.Z.o h��frr3]Er �� City TocK.Td Contractor's Name 1",4AL'N /�Gtf (t/License'#tY_-(9 ES7 Business Phona 9</ 7 — 0-39 Z i Contractor's Address �'�Rs0 &CAI0 C-11, Emergency Phone S: rrr Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ / 5-0-/- .0-1DISTANCE TO NEAREST: Septic Tank � ( Sewer Lines +�0-/ Pit Privy Sewage Disposal Field f't.C�t.Z ._ Cesspool/Seepage Pit Cy " Other kL&nr Property LinePrivate Domestic WellPublic Domestic Well INTENDED USE TYPE OF WELL i ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation f� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 51Y ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing © IRRIGATION t❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION pl ROTARY Type of Grout 4i e-T �c7T)C � , ❑ DISPOSAL ❑ OTHER Other Information -YO ) ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump R H.P. ° PUMP REPLACEMENT: ❑ State Work Done f PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe NBterial and Procedure 75 4?A1A_II? 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. Homeowner 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-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall em p sons subject to workman's compensation laws of California." Ill call for a Grout n o rio to grouting and a final inspection. Sig Title: /V G L Date: � 2 (Draw Plot Plan on Reverse Side) - c 1 7 FOR DEPARTMENT USE ONLY I + PHASEI Application Accepted By Date �d Additional Comments: Pha a II G out In�pe�cDatsn Ph 4e I Final Inspection Inspection By e_fes 2 4PP- Inspection.By� Date 7 ~ I i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT `t PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 j REMIT I BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER 4 r� OTHER o Received by Date I 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_