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AppliiIP8e—ProcessedWheted Properly Completed. BeSureToSignTheApplication Im ��11f FOR OFFICE USE: o SEP 8 10•� IMPLICATIONNon-Transferable, Revocable,Suspendab e) PUMP&WELL SAN JOAQUINEM NMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) HEALTH DISTRICT WATER QUALITY Application is hereby made to the San 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 Local Health District, Exact Site Address 6770 N_ Wept T,ane City/Town Stockton _ x Owner's Name _BQbby smith Tr Phone 477-2-96 Address City Contractor's Name gprm n r c t.7n+or � � License#26 F,96 Business Phone Contractor's Address 1.243 Charryland Ave. - Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 41— WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT"❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other ' Property Line Private Domestic Well Public Domestic Well ADESTIC/PRIVATE ENDED USE TYPE OF WELL STRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DRILLED Dia. of Well Casing ESTIC/PUBLIC ❑ DRIVEN Gauge of Casing , ❑ IR IGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ C THODIC PROTECTION ❑ ROTARY Type of Grout ❑ SPOSAL ❑ OTHER Other Information ❑ EOPHYSICAL Surface Seal Installed By: P INSTALLATION: Contractor r Type f Pumpc�1'hm H.P. 5 . PUMP REPLACEMENT: State Work Done r ��aced Exl�t 1 nrT m1mx� Lr; 1 1, n �5 u1, PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter. Approximate Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County w ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. it 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 sub-contracting signature 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 call for a Grout Inspection prior to grouting and a final inspection. Signed X 7� Title: c-sCr ' ��J Date: (Draw Plot Plan on Reverse Side) OR DEPARTMENT USE ONLY PHASEI Application Accepted By mm% Date Additional Comments: Phase II Grout Inspection Phase eIIII Final Inspection Inspection By Date Inspection By = T Date Fee Is Due: ❑ ANNUALLY '❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING 3 1- REMITTANCE BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT y Q FEE , LESS PRORATION PLUS PENALTY { OTHER li OTHER Received by Date Receipt No Permit No. - 144suance a e Mailed Delivered APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O.Box 2009 -STOCKTON,CA 95291.