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It Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION Z y Pr Non-Transferable,Revocable, Suspendable) / PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application Is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal I the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address V`22 �,G LG y City/Town Owner's Name " Phone Address 9 F )L ST City Contractors Name IA40MEn (4 )) License If 2a Business Ph9e 2 7.2— o I Contractoes Address aoo S%ga AT1?i Emergency Phone j Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes NP 6� TYPE OF WORK (CHECK); NEW WELD DEEPEN ❑ RECONDITION DESTRUCTION❑ .JC__ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT❑ A - DISTANCE TO NEAREST: Septic Tank j=7 Sewer Lines Pit Privy Sewage Disposal Field_1QDJc'T- Cesspool/Seepage.Pit Other Property Line Private Domestic Well Public Domestic Well y INTENDED USE TYPE OF WELL „ 1 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6� ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - ❑ IRRIGATION GRAVEL PACK Depth of Grout Se ` 13CATHODIC PROTECTION .�ROTARY Type of Grou ` il/S11N)7� ❑ DISPOSAL ❑ OTHER Other Infor ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Q Type of.Pump H.P. Oa PUMP REPLACEMENT: - ❑ State'Work Done PUMP REPAIR: ,State Work Done DESTRUCTION OF WELL: 'Well Diameter Approximate Depth I Describe Material and Procedure t I hereby certify that I have prepared this application an,2 that the work will be done in accordance with San Joaquin County ordinances,state laws, and rules and regulations of the an Joaquin Local Health District. Home owner or licensed agent's signature certifies the follbwing:"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." , Contractors hiring or sub-contracting signature certifies the following:"I certify that tri the performance of the work for which this Permit is Issued, I shall employ persons subject to workman's compensation laws of California. - I will ea for Grout Inspection prior to grouting and a final inspection. Signed X e —_—, Title: Date: , • (Draw Plot,Plan on Reverse ide) FOR DEPORTMENT US ONLY PHASE 1 ;+ � �/ Application Accepted By %� Date L Additional Comments: as I ut Inspectionq - P_hJase III Final Inspection Inspection By Date��/, "�y, Inspection By N'�•.�. Date Fee Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Receivod By January 31 ❑ July 1 A Receival By July 31 REMIT ,BILLING REMITTANCE S BASE ExPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 3 o LESS PRORATION " PLUS PENALTY - OTHER OTHER _5 Received by Dale Receipt No. Permit No. luu Date Mailed . Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1991 E.HAZELTON AVE.,P.O.Boa 2999 STOCKTON,CA 95201