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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: ,APPLICATION: / r Non-Transferable,Revocable,Suspendable) - �{ PUMP&WELL �`� ENVIRONMENTALHEALTH PERMIT (COMPLET IN TRIPLICATE)Vf"7d.1/t.�'./09 WATER QUALITY Application' hereby made to the San Joaquin Local Health District for a permit to const ruct and/or install the work herein described.This application is made in cor4iiance with-San Joa uj county /prdinance No. 1862 andel the rules and regi4lations of the San Joaquin Local Health District. 0 Exact Site Address ,l '�`�'� �� -'"— Owner's Name Phone X ry�,f��.-2- Address City' _ Contractor's Name Li ansa fi p��0 Pf 3 Business ho _,0-2.5— I Contractor's Address Emergency Phone Is Certificate of Workman's CompensationIn urance on File With SJLHD? Yes No 1 TYPE OF WORK (CHECK): NEW WELL - DEEPEN ❑ RECbNDITION❑ DESTRUCTION❑ WELL CHLORINATION 0 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy , C Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well t— INTENDED USE TYPE OF WELL ❑ 13 �Z / INDUSTRIAL CABLE TOOL Dia.of Well Excavation -SJ DOMESTIC/PRIVATE O DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ID DRIVEN Gauge of Casing ❑ IRRIGATION. �Jam�'/GRAVEL PACK, Depth of Grout Seal ElCATHODIC PROTECTION JA?.ROTARY Type of Grout ❑ DISPOSAL OTHER Other Information' 0 GEOPHYSICAL Surface Seal Installed By:- 6 �� PUMP INSTALLATION: Contractor Type of Pump .H.P. PUMP REPLACEMENT: O'state Work Done PUMP REPAIR: ❑ State Mork Done,. DESTRUCTION OF WELL: 1 Well Diameter • Approximate Depth Describe Material and Procedure I hereby certify that t have prepared this application'andthat 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 ownerorlicensed agent's signature certifies the following:"I certifythat intheperformanceof the work for which this permit Is issued. I shall not employ any persor) in,,such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-Contraeting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shalt emptoy�persons subject to workman'sf compensation laws of California." . I will all for a Grou 11nsp tion pr�or to grouting and a final InCspec�tion. c.../,/�1 0 Signed X J ��~it � 7 �.�-c/ Tllle: / / !'/L.O'� L Date: cPo (Draw lot Plan on Reverse Side) .; `. ^I ' FOR DEPARTMENT USE ONLY PHASE 1 / Application Accepted By ` J_1 {) Date 6 Cl I Additional Comments: - ;'_� Pl e t rout Inspection - Phase III Final Inspection 71 Inspection By�fW��. Date. �' �� Inspection By Date - Date Fee IS Due: Q ANNUALLY ❑PER UNIT ❑ PER SITE .- ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 a Received By July 31 REMIT eASe EXPLANATION BILLING REMITTANCE 'S AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER `/ M V D- 1 Received by Date Receipt No. Permit No Issupbm Dati Mailed Delrvemd APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2005 STOCKTON,CA 95201