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Applications Will Be Processed When Submitted Properly Completed. Be Sure To fign The Application. n I FOR OFeICE USE: - APPLICATION hOT� t• ' I Non-Transferabte, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT 12 Ile -a-/ . (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 Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address19-,9- G-) t City/Town s ' Owner's Name - + Phone 6, -- 0 Address Contractor's Name ` Licenses K3$r2 Business Phone Contractor's AddressEmergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): . NEW WELL 'DEEPEN ❑ RECONDITION❑ DESTRUCTIONN❑ WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER 0 PUMP INSTALLATION El--�PUMP REPAIR REPLACEMENT - %- DISTANCE TO NEAREST: Septic Tank Sewer tines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other_ d Property Line Private Domestic Well Public Domestic Well INTENDED USE " TYPE OF WELL. ❑ INUSTRIAL O CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout `^ ❑ DISPOSAL ❑ OTHER Other Information W7 13 GEOPHYSICAL y' �JL SuAaCe/S/eal1 13rd By: 07. PUMP INSTALLATION: Contract ) LP.Y�_ Type of Pump _ _ H.P. PUMP REPLACEMENT: P State Work Done PUMP REPAIR: p State Work.Done - ---- DESTRUCTION OF WELL: ' Well Diameter Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws,and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that In the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's Compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workmen's compensation laws of California:' h6n4or a Grout Inplipection prior to grouting and a final Inspection. Sig Title: �L!1:- JL.4 Date: �$- (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By ////// Dale�� Additional Comments: Phase It Grout Inspection h e incl Inspection - Inspection By Date Inspection By 1n_ Date �7-02.3-fj Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ' ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 91 ❑ July 1 &Received By July 91 REMIT BASE EXPLANATION , BILLING. REMITTANCE $ AMOUNT DUE CHECKED DATE 1 DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER " OTHER lg6c 0 I�yi z Received by Date Receipt No. Permit No. Issue a Date Mailed. Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Be.2999 STOCKTON.CA 95201