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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 17.911 OFFICE USE: APPLICATION def r 'or Non-Transferable, Revocable, Suspendab. PUMP&WELL /—� J ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) �TQ/(r4�"'lL� WATER QUALITY . Application is hereby made to the San Joaquin Local Health District fol a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquian CoulntyoOr finance No. 1n862 and the rutets�and re ulati ns of the San Joaquin Local Hgalth District. Exact Site Address o2a�77X ti� ,o/YL! ,5.,�� r.1oL( ] CJ l�tl//fe/7 *�ity/fown nr —ea S]h.s'l/d�: Owner's Name A Phone Address - 12 IV, City Contragtor's.Name /� License It s2'DA/3 Business Phone. Contractor's AddressT Emergency Phone I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK):* NEW WELLJ( DEEPEN ❑ RECONDITION 11 I DESTRUCTION❑ WELL CHLORINATION.O WELL ABANDONMENT❑ OTHER ❑ .PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ - UV DISTANCE TO NEAREST: Septic Tank " / Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other C' Property Line - Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL �11 INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation la DOMESTIC/PRIVATE p DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC Q DRIVEN - Gauge of Casing /lo/J LlJ20�� ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ..L_. CATHODIC PROTECTION 18f ROTARY Type of Grout DISPOSAL - 11 OTHER Other Information — ❑ GEOPHYSICAL Surface Seal Installed By PUMP INSTALLATION: Contractor Type of Pump - H.P. PUMP REPLACEMENT: ❑ State work Done PUMP REPAIR: I .P State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth od Desipribe 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 workman's compensation laws of California:' I wit call for a Grout sp 'on prior to grouting and a final Inspe�ctionn. `�'•T,, Signed XQ�.C,CJl/ Title: //l � �1 \L[°l . Date: ( aw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I n �_ a p Application Accepted By � f�X Date O Additional Comments: _ P`h `rout Inspection Phase III Final I paction Inspection By Cw / '� Date-/7-'�� y Inspection By wsa Date Fee Is Due: ❑ ANNUALLY Q PER UNIT p PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 4 LESS PRORATION PLUS PENALTY OTHER OTHER 6 � /b � Received by Dale Receipt No. Permit No. Iltsuance Date I Mailed. Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201