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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable;Suspendable) PUMP&ebtl. ENVIRONMENTAL.HEALTH PERMIT (COMPLETE IN TRIPLICATE) ,WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with Sr Joaq in Count rdin ce No. 1862 and t e rules'and regulations.of the Sa quin Local Health District. ' Exact Site Address y City/Town Owner's Name k,IWPhone Address O �41 City V-) Contractor's Name License# ,z.. ' Business Phone' Contractor's Address r - Emergency Phone ,Is Certificate of Workman's Compensation Insurance on Fil With SJLHD? Yes�� No TYPE QF WORK (CHECK): NEIN WELL❑ DEEPE ❑ RECONDITION t� DESTRUCTION❑ - - v WELL CHLORINATI ❑ WELL ABANDONMENT 13OTHER 11PUMP INSTALLATION❑ PUMP REPAIR❑ - REPLACEMENT � a DISTANCE TO NEAREST: Septic Tank I 6 Sewer Lines Pit Privy A Sewage Disposa Field Cesspool/Seepage Pit Other - va a Domestic Well Public Domestic Well Property Line Pri ; INTENDED USE E OF WELL r t ❑.INDUSTRIAL . CABLE TOOL Dia. of Well ExcavationCA (k),-elj ❑ MESTIC/PRIVATE 11 DRILLED Dia. of Well Casing tGd DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ` ❑ IRRIGATION 4;: ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ° ❑ DISPOSAL 'i ❑ OTHER . Other Information ❑ GEOPHYSICAL I Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. , PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: i Well Diameter Approximate Depth „ Describe Material and Procedure i ` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state'law% 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 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of Califorriia." will call for a rout Inspection prior to grouting and a final inspection. a Signed X A I CK-0-iTitle. _ Date: (Draw Piot Plan on Reverse Side) 11 } FOR DEPARTMENT USE ONLY PHASE I �s F Application Accepted By Date Additional Comments: Phase'II Grout Inspection - tJanuary nal spection p� Inspection By Date Inspection Byate le, "p I Fee Is Due:-❑ ANNUALLY - '❑ PER UNIT. ❑ PER SITE �❑ EACH ❑ January i &Re i e ❑ July 1 &Received By July 31- - REMIT BASE ..+ EXPLANATION BILLING REMITTANCE- $ -.AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE ' LESS - _ PRORATION PLUS PENALTY OTHER 1. k OTHER, 11 - Received by Dat - Receipt No. Permit No.. Is uan a Date Mailed Delivered, _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 Oct }