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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I FFICE USE: APPLICATION . Non-Tragsferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEAI.TH PERMIT AOT— `f / (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. E%ac 'e Address �q3,6 - - 'city/Town, Owner's Nam/a 0dK L-e'er='lL Phone �—Z— Address ! f -,—wCo - City ' Contractor's Name ,�,�� DnG�— License#53 -7/ Business Phone�s'�R"r Contractors AddressEmergency Phone Is Certificate of Workman's Compensation Insurance on File,With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL[3 DEEPEN13 RECONDITION❑ DESTRUCTIO,N,❑� WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 1(C PUMP REPAIR 13 REPLACEMENTD - DISTANCE TO NEAREST: Septic Tank _, Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other \ 1 Property Liner_ Private Domestic Weil Public Domestic Well �1 INTENDED USE TYPE QF WELL ❑ I USTRIAL Q CABLE TOOL Dia. of Well Excavation O'DOMESTIC/PRIVATE 13 DRILLED - Dia. of Well Casing .r^ ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing ❑ IRRIGATION Q GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL ''� Surpface Seal)nstalled By: PUMP INSTALLATION: Contractor �yy Type of Pump _ �A H.P. PUMP REPLACEMENT: Q State Work Done ' �q PUMP REPAIR: , ❑ State Work Done V' DESTRUCTION OF WELL: Wei(-Diameter Approximate Depth (/1 Describe Material and Procedure I . l hereby certify that I have prepared ihis,application and that the work will be done in accordance with San Joaquin County ordinances ,state laws, and rules and rego)ations of the San Joaquin Local Health District. - • Home owner or licensed agent's signature oertllles the following 'I certifythat 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 subcontracting 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.", 1 will or Grout I action prior to grouting and a final frispe4tion. Signed X 0 $.i - Title: D'1:L/Lr-Q.U- Date:7-A I—r/ '•(Draw Plot Plan on Reverse Side) ? 1. FOR DEPARTMENT USE ONLY PHASE 1 Application Accepted By T .• . , . Date Additional Comments: Phase 11 Grout Inspection gage final Inspection �/, Inspection By Date Inspeciion By fii Date Pee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 11 Received By July 31 BILLING 'REMITTANCE f REMIT BASF EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT u FEE LESS PRORATION 1 PLUS PENALTY OTHER OTHER Received by Date Receipt No. - Permit No. Issuance Date Mailed Delivered APPUCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/ ERVICES 1601 E.HAZELTON AVE,P.O.box 2009 STOCKTON,CA 95M1