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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appilcation. I ) FOR OFFICE USE-71 APPLICATION `t at. 'YA/ 1r Non-Transferable,Revocable,Suspendable• / f n/ -I -/ ENVIRONMENTALPUMP&WELL .� HEALTH PERMIT 1 (COMPLETE IN TRIPLICATE)S'Ikeil, .ZZ� WATER QUALITY Application is hereby made to the San Joaquin Lotat Health District for a permit to construct and/or install the worli herein described.This application is made in compliance with/San Joa In County 0 ddl'''narrr�c__e No. 1862 and the rules and ulation`s�off the$a o quin Local Health Distr`ct. Exact Site Address Y•�QLie,J!!!7 -45Lb � "s'D�`/-�,.-SJ Owner's Name Phone Address +' City J1 s,,� Contractor's Name License q D2?�A/.3 Business Phone ✓ ✓✓ s ContractrA's Address 1 -p Emergency Phone S -L?,27/ :r Is Certifi ate of Workman's Compensation Insurance on File With SJLHD? Yes___X___ No W TYPE O WORK (CHECK): NEW WELL • DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT.❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ / REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank /017 Sewer'Lines Pit Privy . Sewage Disposal Field A00/ Cesspool/Seepage Pit Other Property Line. Private Domestic Well Public Domestic Well 0 INTENDED USE - TYPE OF WELL �� A- 0 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �� , y 101 DOMESTIC/PRIVATE Q DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of;Casing 160/i24z& J ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 11 CATHODIC PROTECTION ROTARY Type of Grout DISPOSAL • ❑ OTHER Other Information y5lah— P GEOPHYSICAL Surface Seal Installed By; _ ' PUMP INSTALLATION: Contractor Type of Pump' H.P. PUMP REPLACEMENT: 0 State'Work Done - I� PUMP REPAIR: ❑ Stale'WOrk.DOne DESTRUCTION OF WELL: Well biameter -;, ' - . .Approximate Depth r 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 pan Joaquin Local Health District. Homeowner 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 rhanner is to become subject to workman's compensation laws of California." r.: Contractor's hiring or sqb-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 willall for a Grout Inspectf prior to grouting. B a final inspection. 1 Date: Signed X �/ Title: 1.LL; (�0 Ca (Draw Pf Plan on ReverserSide) FOR'DEPARTMENT USE ONLY PHASE I Application Accepted By Date O 0 Additional Comments: - V 1' �• Q se ll rout Inspection/1 '/ Pha_seelll�inel Insp ctlon Inspection By/ ' Date -/ Inspection By ��^ �te Fee Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE, ❑ EACH I I1 January 1 6 Received By January 31 ❑ July 1 d Received By July 31 BILLING REMITTANCE $ REMIT BASE '.E%PLANATION AMOUNT DUE CHECKED DATE DATE ' REMITTED. J� ,fir AMOUNT FEE LESS •,- PRORATION �'•' PLUS PENALTY OTHER OTHER �1 s iz M Received by Date Receipt No. Permit No. I uance D to ailed. Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE..P.O.B0.2009 STOCKTON,CA 95201