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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, ,/• ly ) FOR OFFICE USE: APPLICATION ? �d/ �/ y Ir Non-Transferable, Revocable, Suspendable) 'lam PUMP&WELL ENVIRONMENTAL. HEALTH PERMIT (COMPLETE IN TRIPLICATE) �S7diiJEy210f�E �7 WATER QUALITY• Applicatigyy,'Is hereby made to the San Joaquin Local Health District for a permit td Construct"and/or install the work herein described.This applica on is made in bompliance with San Jo quin County 0 din nce No. 1862 and the rules,and rep�lations�of/thg San Joaquin L cal Heal Distri L Exact Sit;Address 1,397n�� u�/}i,f �r - S ii��/�l9�nP� rb�.tL,il�zr�uR� P77��-1 Owner's Name /�Cl/•1 ( �)•9 �'- Phone 1 Address P� �' ,?�n City Contractor's Name - JLLii^cense H c2&Z2 Business Phon��RJ`— Contractor's Address T�O�E o1z9 Emergency Phone 7/ Is Certificate of Workman's Compensation Insurance on File With SJLHD? ' Yes_ i No 1 TYPE OF WORK (CHECK): NEW WELLJe1 DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ t, •\ WELL CHLORINATION ❑ WELL ABANDONMENT ❑' OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 11 REPLACEMENT❑ y DISTANCE TO NEAREST: ',Septic Tank Sewer Lines - Pit Privy Sewage Disposal Field 4W Cesspool/Seepage Pit ' Other (- Property Line 1 -Private Domestic Well Public Domestic Well _ } INTENDED USE TYPE OF WELL ❑ INDUSTRIAL P CABLE TOOL Dia. of Well Excavation�l DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC b❑f DRIVEN Gauge of Casing �L/✓J ��a�-� ❑ IRRIGATION 1y GRAVEL PACK Depth of Grout Seal Q CATHODIC PROTECTION ROTARY Type of Grout Q DISPOSAL OTHER Other.Information O GEOPHYSICAL Surface Seat Installed By: PGLl.LLO� PUMP INSTALLATION: Contractor ' r Type of Pump H.P. PUMP REPLACEMENT: O'S tale Woo(Done PUMP REPAIR: ❑ Stele Work Done DESTRUCTION OF WELL: ,Well)Diameter Approximate Depth Des6rjbe Material and Procedure-17 hereby certify that 1 have prepare& this application and that the work will be done in accordance with.San Joaquin County V ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature ce Ilies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in s6ch'manner as to become subject to workman's compensation laws of California.' Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall enjploy persons subject to workman's comperfsation laws of California." I well all for a Grout I spec> tipP prior to groulin and a final Inspection. 1/y,, Signed X ,�-1.`_(Yl, �-I Tiller' �!-eS.e._ Date: Sa / Cpl (Dew t Plan on Reverse Side): FOR DEPARTMENT USE ONLY PHASEI � C p Application Accepted By , =;{1��— � Date Additional Comments: P( 'se II rout Inspection 4 $/ Phase III Final nspectlon Inspection By 1^ Date ��3 .Inspection By �✓ Date Fee Is Due: ❑ ANNUALLY ❑.PER UNIT ❑ PER SITE. -❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 6 Received By July 31 REMIT REMITTANCE S BASE ,i E%PLANATION AMOUNT DUE CHECKED 'y � DATE DATE REMITTED r AMOUNT FEE 4PLD LESS PRORATION PLUS PENALTY OTHER r• OTHER rn c5 Recurved by ate Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.NAZELTON AVE.,P.O.Box 2D09 STOCKTON,CA 95301