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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. / 133v- Non-Transferable, I FOR OFFJCE USE: APPLICATION 044-1 ^ - I - 131 ,�,% Non-Transferable,Revocable, Suspendable) / PUMP&WELL v 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 wilih.San Joequi County groina a No. 1862 and the rules and regulations of the San-1Jo"aquin Local Health District. Exact Site Address O 2 . ' ' City/Town -, v Owner's Name �"- Phone Q J(D —n 4 2� pQ Address 57— City Z-1,44-"Le— a �- -"Le— -- Contractor's Name License x3�rU7( Busiriess Phone S _. I Contractor's Address if� X u�-- �d'G.bZ=.,0 Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD4 Yes No S TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT,P OTHER ❑ PUMP INSTALLATION Ia--�PUMP REPAIR REPLACEMENT❑ ' DISTANCE TO NEAREST: Septic Tank Sewer,Lines Pit Privy p Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well LO LA INTENDED USE TYPE OF WELL ' �❑ IN_�� J�STRIAL 11 CABLE TOOL Dia. of Well Excavation a/ { DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing 11IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION Q ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL . SuirfacA Seat Installed By: PUMP INSTALLATION: Contractor_ � i 4-1 Type of Pump H.P. — PUMP REPLACEMENT: 0 State Work Done 1V PUMP REPAIR: 0 State Work Done - `- DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure r ' I hereby certify that 1 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. Homeowner 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." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this V permit is issued, I shall employ persons subject Jo workman's compensation laws of California." I will cell a ut InspTeetion odor to grouting and a final inspection. n..... Signed X o _ - Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY ' PHASE 1 _ y Application Accepted By Date Additional Comments: Phase 11 Grout InspectionPha ,Ij'I/}��Fi{nel lnspectl0n p / R Inspection By Date _ Inspection By�I ?J%ic2 Date Fee IS Due: ❑ ANNUALLY ❑ PEn UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 a Received By July 31 REMIT BILLING REMITTANCE $BASE EXPLANATION , DATE DATE MITTED AMOUNT DUE CHECKED AMOUNT Q FEE LESS PRORATION PLUS PENALTY OTHER v - OTHER Received by Date Receipt No. Permit No. Isluarlce Dafte Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Ilei E.HAZELTON AVE.,D.O.Boa 12009 STOCKTON,CA SSMC