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Applications Will Be Processed When Submitted Properly,Conipleted. Be Sure To Sign The Application. 7Applicati ICE USE: APPLICATION . I' 1G1 r V r Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPILE IN TRIPLICATE) S�IJNE�/D�pE �o� WATER QUALITY s hereby madetothe San Joaquin Local Health District fora permit to construct and/or installthewurk herein described.This applicatiln is made in cca npliance with San Joaq in C unty Ordinance[Jo.]S6?and the as and regulations`of the San Joaquin Local Health District. Exact Site Addresser �/1i'��i ip��•'g/� City/.Town Owners Name I `-D ( y` Phone Address 1� b�3'L - .City _7 ,^y/ .—Il._ Contractor's Name r—� +Z/ 'r//�L��iiceenLnsek o290R/3, Business Phone � S—(��S Contractor's Address r r� 4 ��GS �1 17hmefgency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? - Yes_ - No t 1 TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑' RECONDITION❑ DESTRUCTION❑ W WELL CHLORINATION ❑ WELL ABANDONMENT ❑. OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR _ 1 REPLACEMENT❑ r)l/00v DISTANCE TO NEAREST:, Septic Tank � Sewer Lines Pit Privy V Sewage Disposal'Field /GVJ Cesspool/Seepage Pit Other Property'Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 1111 INDUSTRIAL ❑ CABLE TOOL' . Dia.of Well Excavation_ / — la DOMESTIC/PRIVATE . ❑ DRILLED Dia. of Well Casing 42�P�� N A DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - ❑ IRRIGATION GRAVEL_ PACK Depth of Grout Seal b� CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information — '"W 2 ❑ GEOPHYSICAL l• Surface Seal Installed By: PUMP INSTALLATION: - Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State W ork.Done PUMP REPAIR: Q State... rk bone DESTRUCTION OF WELL: Well Di4iKeter• Approximate Depth --/� Oescritie"Material and Procedure I hereby certify that I have prepared this Application and that the work will be dond In accordance with San Joaquin County ordinances, state laws,and rules and�regula�ons of the San Joaquin Local Health District. Home owner 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:' Contractor's hiring or subcontracting signatore 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 all for a Grout In)spee5c�(pn,,,phor to"giouting and a final inspection. /- �, Signed X 17c�(Xd 1. l,/LL Title: �l/.t -� i�=(J �Qiz, . Date:. g jDr4 Alot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date Y Additional Comments: _ t A7 e II ut Inspection Phase III Final Inspection Inspection By 7�, ,U�'Date� Inspection By 4/ Date .l Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Q PER SITE ❑'EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 BILLING" / "REMITTANCE 5 REMIT BASE EXPLANATION DDATE EMITTED AMOUNT DUE CHECKED ATE P AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER / 01 8� 15 J4 Received by ate Receipt No. Perniv No I suan a Dale Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE..P.O.Be.2009 STOCKTON,CA 95201