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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. t FOB OFFIGa USE: APPLICATION 27 r Non-7ranblerable, Revocable, Suapendable, PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) ' WATER QUALITY Application is hereby made to the San Joaquin Lbcal Health District fora permit to construct and/or install the work herein described.This application is made in compliance witSan Joaquin�unty Ord' ance No. 1862 and tha rules and regulations,of the San Joaquin Local Health District. Exact Site Address �,�-,.�,�J�-�Y. ��f ,.77 City/Town O�/ Owner's Name �l L -P l Phone OJb" a22 Address E city-- Contractor's ity_Contractor's Name 4GSd ��,,,,,,,,, �_�L�ii,,c,///ense M cWD.4L?, Business Phone Contractors Address Emergency Phone `-11,7J/ Is Certificate of Workman's Compensation n urance On ile With SJLHD? Yes No TYPE OFq/�,��ORK (CHECK): ' NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL ClTLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLAC�AENT❑ / DISTANCE TO NEAREST:. Sep)ic Tank Sewer Lines Pit Privy Q' Sewage Disposal Field ,[QQ r Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation tDDOMESTIC/PRIVATE DRILLED Dia. of Well Casing OMESTIC/PUBLIC 0 DRIVEN Gauge of Casing ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal Y ❑ CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: o PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: El State Work Done PUMP REPAIR: - ❑ State Work Done . DESTRUCTION OF WELL: Well Diameter Approximate Depth 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. ' Home owner or licensed agent's sig nature certifies the following:"I certify that in the performance of the work for which this permit (\ t is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Q7.Lo Contractor's hiring or sub-contracting Signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California:, (1 1 will sll for a Grout nsp ti' 1 prior to gro ting and a lin I Inspection. .J Signed X Title:- Date: _ (Dr lot Plan on Rev rse Side) / ! FOR,DEPARTMENT USE ONLY PHASE I n Application Accepted By �� Date3 Additional Comments: P e II Grou a ection III Final s ectionP ., Inspection By p StyIe-II- `�'�-k� Inspection Bysa �ate S- el-FX Fee Is Due: ❑ ANNUALLY ❑ PER UNIT y PER SITE ❑ EACH 0 January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT b Da FEE LESS PRORATION PLUS PENALTY OTHER / OTHER rv`� T 3 16d-_73t Received by D to Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA3ELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95391