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:ApplicationsWill Be Processed When Submitted Property Completed. Be Sure To Sign The Application.A FOR'OFFICE USE: APPLICAT10 (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY /UL?LO Oro"5'f4-V-4-C4 r in ot�j Application is hereby made to theSan Joaquin Local Health District fora 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 acat Health District. Exact'Site Address �d / s vc� City/Town Q ,' Owner's Name /^ /i,i r-,4 in 01a/ / top Phone Address d lAsf? � _ City. Contractor's Name uJ(e�i ch !u irlNa License#3'��f� �_ Business Phone :364?-16 7cF Contractor's Address 000 E cQ-*"AO Emergency Phone XoJl-PR K Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No \ TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Ale Sewer Lines t Pit Privy r✓ N�- V Sewage Disposal Field ?egg Cesspool/Seepage Pit . A&Aofe Other No r-Jct.. r Property Lineup f Private Domestic WellVO4/e- Public Domestic Well A?6 0s e_ INTENDED USE TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation Z.2 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing DOMESTIC/PUBLIC DRIVEN Gauge of Casing w ` ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Cie- 4,!/71- El DISPOSAL 0 OTHER Other Information ❑ GEOPHYSICAL` ��e` Surface Seal Installed By: 'e-,PUMP INSTALLATION: Contractor A7.4 Type of Pump r P� 6 H.P. PUMP REPLACEMENT,. ❑ State Work Done PUMP REPAIR: Y❑ State Work Done DESTRUCTION OF WELL: Well-Diameter Approximate Depth Describe Material and Procedure I hereby certify'fliat I'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. ..Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit i§ 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 sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this 4 permit is is"sued,"I shall employ persons subject to workman's compensation laws of California." r i_vA1 call for a Grout Inspection prior-to-grouting and a final inspection. Signed X J Title: - @n�� _ Date: 4 a•, 3 ¢(Draw Plot Pian on Reverse Side) _ FOR DEPARTMENT USE ONLY PHASE 1 n " Application Accepted By Date 7y Additional Comments: Phase II Grout Inspection P se Final Inspection Inspection By., -Date. ..2 -Ins ection B - - - 2 {. - p y _ _ .. - Dale 4 Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SfTE El EACH ❑'January 1 &Received By January 31 ❑ July 1 8 Received By July 31 ' BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED - - ' AMOUNT FEE LESS PRORATION i PLUS PENALTY y OTHER 3 ] OTHER -7 ) - ?AP'P11'CA by ate � Receipt No. Permit No. � Issuance Date Mailed Deliveed NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 a .,