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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 FOR K-FICE USE: - APPLICATION !a y Non-Transferable, Revocable;Suspendable) '9 PUMP&WELL i ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY T Application is hereby madetothe San Joaquin Local Health Districtfora permit to construct and/orinstall thework herein described.This application is aQ made in compliance with San Joaqujn County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. t- Exact Site Address ��7 w• ST N�R%/ZGc city/Town %d'49 Y Owner's Name -D oN coS6'V- Phone 836 Address __c-.l G. S� - City.�� C J / Contractor's Name ��l! /i4S L-[E�C; T/itG. License ti33rSY7/ Business Phone__ � Contractor's Address .�/,. y?3vir Emergency Phone Is Certificate of Workman's Compensation Insurance on File W thSJLHD? Yes_I(— No. � TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO,,NLL,❑, •� WELL CHLORINATION ❑ WELL ABANDONMENT'[] OTHER Q PUMP INSTALLATION to ` PUMP REPAIR❑ REPLACEMENTD DISTANCE TO NEAREST: Septic Tank _,. _ Sewer Lines Pit Privy' Sewage Disposal Field- CAsspool/Seepage Pit- Other P.roperty.LinePrivate Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL '1 ❑I� INDUSTRIAL Q CABLE TOOL _ Dia.of Well Excavation IX-DOMESTIC/PRIVATE P DRILLED Dia.of Well Casing ❑ DOMESTIC/PUBLIC! ❑ DRIVEN Gauge of Casing Q GRAVEL PACK Depth o1 GroutSeal❑ IRRIGATION i ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout O DISPOSAL Q OTHER Other Information ❑ GEOPHYSICAL _ Surface Seal Installed By: PUMP INSTALLATION: Contractor Type o1 Purhp ' . I H.P. �Z PUMP REPLACEMENT d State Work Done PUMP REPAIR: d State Work pone DESTRUCTION OF WELL: Well Diameter / I 'Approximate Depth Describe Material and Procedure I I i I hereby certify that I have preparedk'lhis application and that the wo will be done iri accordance with San Joaquin County ordinances.istata laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's sigpeture certifies the following:"I certify hat to the performance of the work for which this permit is Issued, I shall not employ,any person in such manner as to become sub)ecl to workman's compensation laws of California." Contractor's'Ihiring or sub-contracting signature certifies the following:"I certifohal in the performance of the work forwhich this permit is' ued. I shall employ persons subjecto workman's compensation laws,of California." ). I will rout sped to grouting And a final Inspection. ' Signed X Title: ., !-c/L`Q�c Date: '� �►; (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI r Application Acce lied By � ' DateOr "aAtlditional Comm¢nts: Phase II Grout Inspection `. -I'Phase III--F-inal Inspection Inspection By Date Inspection By py�Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Q PER SITE EJ EACH. ❑ January 1 E Received By January 31 ❑ July 1 8 R By July 31 BILLING EMITTANCE s REMIT ! BASE E%P.LANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 914 LESS Q PRORATION PLUS _ PENALTY OTHER OTHER ' `79-111 Loft loilb/ 7� Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON.CA 95201