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Applications Will Be ProcessedWhenSubmittedProperlycompletes tie sure Iosign IneAppllcauon. ' icy USE: APPLICATION (Far Non-Transferable, Revocable,Suspendable} PUMP&WELL ENVIRONMENTAL HEALTH PERMIT COMPLETE iN TRlPL1CA7E p WATER UALL Y �D$- j?7f —01 Application is hereby made to the Santo`aquinLocalHealthDistrictforapermi o construct and/or install the work herein described.This application is made in compliance with San Joaquin C u y Ordinanc No. 1862 a d the rules n regulations of the San Joaquin Local Health District. Exact Site Address /Ws' /0/6j - City/Town I Owner's Name I & 41k 0 Phone Address City Contractor's Name License# 001 —7 Id Business Phone �1 Contractor's Address v Emergency Phone { Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL_❑ DEEPEN RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION Cl 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 Weli Public Domestic Well �F INTENDED USE TYPE OF WELL O 1 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ 0 IRRIGATION k SOLO © GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL "@'THER Other Information n a ❑ GEOPHYSICAL Surface Seal Installed B PUMP INSTALLATION: Contractor Type of Pump H.P. I PUMP REPLACEMENT: State Work Done PUMP REPAIR: ® State Work Done .. I k DESTRUCTION OF WELL: Well Diameter Appro imate 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:N 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 California." ' I wit Fcall for a Grout Inspection rio t ro ting nd a final inspection. Signed X _ Iw_ J _ Dale: ! (Draw Plot Plali on Reverse Side) FOR DEPARTMENT USE ONLY PHASE 1 Application Accepted By 5 Date `7 It 5 mo Additional Comments: Phase 11 Grout Inspection a til F'Lpfal Inspection _ Inspection By Date Inspection By' Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 REMIT 1. BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AM0,IJLqT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date - Receipt No. Permit No. Issuance rraie Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520"