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Applications Will=-eeVirocessed When Submitte-d-P—roperly Completed. Be.Sure T-0-Sign The Application. FOR OFFfCE~USE: /t «, _. . APPLICATION' -(For Non-Transferable,Revocable, Suspendable) 4,k -+""" PUMP&WELL - Ar'w------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 incompliance with San Joaquin County Ordinance No.:862 anti,the rules and regulations of the San Joau�in!�•Local Heal District. Exact Site Addressn t?+t. � r�1 '�� i T`� .. �°�� +r S!�.� dr)�,��j'�" City/Tom. Owner's Name �?f��. ' le-rid. �t " 11't9(1�Mfr.' "[! ' �,,.!) U..J Phone Address o f ��>Frr>' r f+. •S 7t-- City Z d C '�- Contractor's Name S-46%,*..-./ License k /�&7Z C Business Phone Contractor's Address eE CZ5& c �' Emergency Phone Is Certificate of_Workman's Compensation Insurance on File With JLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRffi REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit tither 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 .® IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other information ❑ GEOPHYSICAL Surface Seal Installed By: t PUMP INSTALLATION: Contractor f//r Z, Type of Pump "Tr j• ffjtl H.P. c ; PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: State Work Done C-11 rr 1rr 422 DESTRUCTION OF WELL: Well Diameter 7 A r pproximate Depth Describe Material and Procedure j 6 I 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 ahy 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 forwhich this permit is Issued, I shall employpersons subject to workman's compensation laws of California." 'I will call for a Grout Insspection•'prlot to,groo ng and a,fin�al inspection. J /fir Signed X 'Jtl r �?Ar— F� — a- - Title• Tr'--J Date: (Draw Plotglan on Reverse Side) f DEPARTMENT USE ONLY PHASE I �e1 Application Accepted By =---��r Additional Comments Phase II Grout Inspection Phase III Final Inspection Inspection By _`I Date Inspection By Date Fee Is Due: ❑ ANNUALLY, PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS s PRORATION PLUS O PENALTYng f OTHER OTHER03 I i�� Received by Da Receipt No- Permit No. Is.L ante to Mailed Delivered APPLICANT.—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 y E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 • - .