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'. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T FOR OFFICE USE:. , APPLICATION E4P f=O U Non-Transferable, Revocable,Suspendable) Y PUMP&WELL , .ENVIRONMENTAL HEALTH PERMIT WATER QUALITY 14(COMPLETE IN TRIPLICATE) Application is hereby mage to the San Joaquin Local Healllh District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.1862 an )he rules and regulation;sDif thSan Joaquin peal Health District. Exact Site Address_�D�/,� JJ S�a?S t�/ � �C/, J —�(Df � " s�"Cti-7To7"el + ' Y -r Owner's Name �Q.t'�._�.e=��.�' Phone Address - ' , -City - Contractor's Name _ DJ• License ft-04n.5/.3 Business Phone .SSSS- '7 Contractors Address j� ergency Phone 'S V5'-fJo?71 Is Certificate of Workman's Compensation Insurance on ile With SJLHD? Yes X— No __nn TYPE OF WORK (CHECK): NEW WELD, DEEPEN Q , RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ ~ REPLACEMENT❑ •' DISTANCE TO NEAREST: Septic Tank X00 'Sewer Lines Pit Privy W Sewage Disposal Field /0 n r Cesspool/Seepage Pit Other , o Property Line Private Domestic Well Public Domestic Well \ INTENDED USE TYPE OF WELL r1 r ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well ExcavationC DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing - y77 PVG ❑ DOMESTIC/PUBLIC ❑ DRIVEN - Gauge of Casing 160zyagze ❑ IRRIGATION §GRAVEL PACK Depth of Grout Seal—� 11 CATHODIC PROTECTION r y ROTARY Type of Grout -, I Ln� ❑ DISPOSAL ❑ OTHER Other Information -)kz6 -beO Q GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: ,Contractor' Type:of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: Q State Work Done 1 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.peisim in such manner as to become subject to workman's compensation laws of California:' Contractors hiring orsub-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 workman's compensation laws of California:' 1 will call for a Grout Inspection prior to grouting and a final inspection. �y/1� �� q Signed X �LZ � Title: vr ` Date: O �� ;( aw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By d�=, A-tx� ^'�� [ Ir -Q- Date I Additional Comments: al • ,�,,,,Plp�asp�l Grout Inspection 5 Phase III Final Inspection Inspection By f1 Y!_¢ Date .� �5 -�� Inspection By 0-4�1Z Date . Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 A Reeelved By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATIOTt, DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY - OTHER t , OTHER ov LR—�.c,ei,Le,lvy ale Receipt No. Permit No. Issuance Date Mailed Delivered ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..D.O.Boa 2009 STOCKTON.CA 95201