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"'��Applicatlons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION e rt p//rn (For Non-Transferable, Revocable,Suspendable) _ n ENVIRONMENTAL HEALTH PERMIT Y PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permitto'construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.1862 and t e rules and regulations of the San Joaq In Loc I Health District. Exact Site Address' / City/Town Owner's NamePhone Address &-77l� A/. 'rfe+ � _w �c�b.(�. City__ Contractor's Name License# 1&77<r� Business Phone 4 - Contractor's Address GEmergency Phone l� i Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes._ No 0 TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ - PUMP INSTALLATION® PUMP REPAIR❑ 06 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 r ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 01 ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL 'Surface Seal Installed By: PUMP INSTALLATION: Contractor +` t a Type of Pump - H.P. PUMP REPLACEMENT: ❑ State Work Done R43M+P"RtP'AIR: State Work Done DESTRUCTION OF WELL: Well diameter App oximate Depth � Describe Material and Procedure I hereby Y certif 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." r Contractor's hiring or sub-contracting signature certifles 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 wii call for a Grout Inspection rlor tc Ing an final Inspection.- i t Signed X isle: _ x Date: (Draw Plo Ian on Reverse Side) { FOR DEPARTMENT.USE ONLY PHASE I Application Accepted By r ` Date Additional Comments: i Phase 11 Grout Inspection Phase II Final Inspection fo� Inspection By Date Inspection By Date 3-1 -96 I 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 v AMOUNT ` A S : 5 FEE LESS PRORATION PLUS �- PENALTY - OTHER OTHER 1 Received by Date -Receipt No. PermiUNo�� I uan a Date Mailed Delivered---- APPLICANT—RETURN ALL y COPIES TO: -r ENVIRONMENTAL HEALTH PERMITlSERYiCES � 1fi01 E.HAZELTON AVE.,AYE.,P.O.Box 20 -STOGKTON CA 95209 -F,