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Applications Will Be Processed When Submitted Properly Completed. Be Sureo Sign The Application. ) FOR OFFICE USE: APPLICATION .- - Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE I��TR IF IC ATE) SJTO/1JE/p/OL'� WATER QUALITY Applicationist ,reby.made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.Thisa plication is made in compl!! nce wait/h�San Joequin CountyPrdinance No..1862 a d the rules and regulations of the San Joaquin Local Health District. Exact Site AddI ss�/ �/'� ''r -t' City/Town Owner's Namo" t Phone Address City 7r' � Contractor's Name License NQ_1?/3 Business Phone L53�S//,F'i� Contractor's Address Emergency Phone _ Is Certificate of Workman's CompensationIp urance on File With SJLHD? Yes _ No ` TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ - RECONDITION DESTRUCTION❑ W WELL CHLORINATION ❑ .WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ / DISTANCE TO NEAREST: Septic Tank_! Sewer Lines _— Pit Privy Sewage Disposal Field_ /OD / Cesspoot/Seepage P.it. Other Property Line Private Domestic Well Public Domestic Well �— INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation X DOMESTIC/PRIVATE P DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC 0DRIVEN Gauge of Casing 11IRRIGATION /fwd GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION yp,ROTARY Type of Grout D DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done _ PUMP REPAIR: . - State Work Done l ` DESTRUCTION OF WELL: Well Diameter Approximate Depth (Ll Describe Material and Procedure Lo 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'saignature certities the following:"I certify that in the performance of the work for which this permit 7O is issued. I shall not employ g6ylperson in such manner as to become subject to workman's compensation laws of California." O Contractor's hiring or subcontracting 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:' I will call for a Grout Inlsspi:eCc�tiio'nprior to groutin 'g .. and a final Inspection. t. ,./,,/" Q� Signed XU(•(•et LY�' S11 ( 1+�P Title: �.G(_��`-�r�r ¢7 `"-�' Date: 57/.2 —� Dra lot Plan on Reverse Side) (/ FOR DEPARTMENT USE ONLY PHASE I a&+ 8 Application Accepted By — Date Additional Comments:, Ph se I rout Inspection - Phase III Final Inspection 2-81 Inspection By Date� Inspection 0y_16406Z Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE''*., ❑ EACH p January 1 8 Received 6y January 31 ❑ July 1 S Received By July 31 REMIT 'BILLING REMITTANCE S BASE - EXPLANATION i'pA7E DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE r LESS s PRORATION ' PLUS PENALTY OTHER OTHER x Recelved by D e Receipt No. Permit Iss ante Dille Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE..P.O.Box 2009 STOCKTON.CA 9S201