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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICi USE: q APPLICATION ,f raps �a 44:X (For Non-Transferable, Revocable, Suspendable) pUMp&WELL I ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permitto 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 Joaq in Loc I Health District. Exact Site Address / a ,- lrao G�1-1-46 'L Z6 City/Town S Owner's Name It- 0 _ 4- Phone Address 1.3 City Contractor's Name License# Business Phone Contractor's Address k. Emergency Phone i Is Certificate of Workman's Compensation Insurance on File With SJ D? Yes_ 1� No 1 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ C16 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION CS PUMP REPAIR❑ v, 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 INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal © CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor ti H.P. Type of Pump { PUMP REPLACEMENT: ❑ State Work Done PUMP4WwPA4A: ® State Work Done =,Az 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 _ 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 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." 1 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 sub'e o workman's compensation laws of California." al r 1 W'1 call for a Grout In ct on r' r tp rut' nd al inspecti Signed e: Dater ' (Draw Plot Plan on Reverse Side) -� FOR DEPARTMENT USE ONLY PHASE [ Application Accepted By •M�� 4/ Date W b 6V Additional Comments: Phase II Grout Inspection hase 11 Final Inspection 1 J '7 Inspection By Date Inspection By ate _i r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED' DATE DATE REMITTED AMOUNT Y r FEE yrj U LESS PRORATION PLUS PENALTY OTHER OTHER r ADo>� (0 Received by Date - Receipt No. hermit No .-Issuarke Date Mailed Delivered . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009_ STOCKTON,CA 95201