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Applications Will Be Processed When Submitted ProperlyILompleieo. ae auras 1uargir r �rr•••�•••• FOR OFFICE use: APPLICATION -a (For Non-Transferable, Revocable, Suspendable) j PUMP&WELL I ' ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is r made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address .nit Rf7R� _ F OVA a5C 1-ff— City/Town A "'lik S-e_ vlr 1 Owner's Name .S•T1 cowy FMIC W04S XP ' Phone 944 -2281 Address /9/0 E, &42CL771N RE-2Y257 ST4G Contractor's Name O- r e GF LOGS lg License# E-2Y2� Business Phone /� Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Noi TYPE OF WORK (CHECK): NEW WELL. DEEPEN ❑ RECONDITION❑ DESTRUCTIONK ' WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property tine Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 3.y !. 11 INDUSTRIAL CI CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED " Dia. of Well Casing ❑ DOMESTIC/PUBLIC 09 DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION 19 ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information X GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter 3l� Approximate Depth Describe Material and Procedure ABCCG Fi// 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:"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." R. I WAcall for a Grout Inspection prior to grouting and a final inspection. Signed Xo a Title: .Ss • S�i-�eUr�s Eh Date: '� ~ '�`83 (Draw Plot Plan on Reverse Side) ��rl�j� ��. Or �►� � FOR DEPARTMENT USED LY PHASE I Application Accepted By Date —X 2- Additional Commen a e II rout Ins ection PI se III Final Inspection 2 Inspection By e _ f Inspection By ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &ReceivedREMITuly 31 - .. { BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT r ' FEE C= LESS PRORATION PLUS PENALTY OTHER – OTHER Received by Date Receipt No. Permit No. - Is vancla Date Mailed Delivered 't. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21109 STOCKTON,CA 95201 J