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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �f FOR OFFICE USE: ` 'APPLICATION . `�• �,r/ .. •r Non-Transferable, Revocable, Suspen fable) / PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) , WATER QUALITY , Application is hereby made to theSan Joaquin LoCpI'Health District for a permit tobonstruct and/or install the work.herein described.This application is made in compliance with:San Joaquin County Ordinance No. 186�'arld the rules and regulations of the San Joaquin Local Health District. Exact Site.Address_B_]IlEri4e. nT_ T10t_.2L_Zf-nnaA -g-p—. ubj�ity/Town Owner's Name Dale COSe PtTone -� AddressP-•0• BOX �Z6_ City�T>•a C Contractor's Name Re11R11g8 2 �BTOS, License# .9D$ Business Phone�li .�$� Contractor's Address'�nn�CC1Pelanda le•1 M des±,o_ Emergency Phone 545s0271 p Is Certificate of Workman's Compensation Insurance on File With_SJLHD7 Yes��_ No Gil TYPE OF WORK (CHECK); NEW WELI_PO DEEPEN ❑ RECONDITION❑, DESTRUCTION❑ WELL CHLORINAT)ON ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑. ' I � 41 DISTANCE TO NEAREST: Septic Tank T_ Sewer Lines Pit Privy Sewage Disposal Field__j_0_01 Cesspool/Seepage Pit Other 4 Property Line Private'Domestic Well Public,Domeslic Well �. INTENDED USE TYPE OF WELL. ' ❑ INDUSTRIAL O CABLE TOOL Dia. of Well Excavation ti 1 PVC F DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing 6 1" PVC ❑ DOMESTIC/PUBLIC Q DRIVEN• Gauge of Casing WALL Q IRRIGATION M GRAVEL PACK Depth of Grout Seal_ 501 ❑ CATHODIC, PROTECTION ® ROTARY Type of GroutCEMENT ❑ DISPOSAL Q OTHER Other Information SLAB—BY OWNER Q GEOPHYSICAL - Surface Seal Installed By: DRILLER PUMP INSTALLATION: Contractor _ Type Of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done — PUMP REPAIR: (ff(�l Stale Work Done - DESTRUCTION O(I WELL. Well Diameter Approximate Depth 0o 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. Nome owner or licensed agent's�Ignatu re certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ anyperson tn,such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall employ persons Fkubject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a fins) Inspectio Signed X HGINNINGS BROS. BY Dale:Dale: 12-1 -80 (Dr.wh Plot Plan on Reverse Side) _ FOR DEPARTMENT USE ONLY '. PHASE Application Accepted By_de,nzG��~ --=� t Dated Additional Comments: ' hose II Gr ul Inspection - se III FI 1 Inspection Inspection 8 Date- �--'��—�� Inspection By Date��1✓�� t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 b Received By January 31 ❑ July 1 d Received By July 31 REMIT BASE 6PLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE. DATE REMITTED AMOUNT FEE y3. D.TF LESS PRORATION PLUS PENALTY OTHER 1 OTHER 1 o 1.2-LYa rJ SS�� 6 L��02. rQ /lab0 Received by Date ReceiPi No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95201