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ca o s Will Be ProcessedN Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: 1 JUL 1218$2 APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL N r.� a L VJRONMENTAL HEALTH PERMIT SA ,(COMPLETE IN TRIPLiCATL EALTH DISTRICT .WATER QUALITY Application is hereby made tothe San Joaquin Local Health District•fora permit toconstructand/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.1862 and the ru s and regulations of the San aeq Local Health District. vet City/Town , Exact Site Address 7 AJTo Phone Owner's Name S %sJ Tom?Yt'1 :, ' �� .� - Gity Address Business Phone +' License# Contractor's Name r "Emergency Phon Contractor's Address ��f No ` Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes '— ❑ J TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ 'RECONDlTlON❑ DESTRUCTION V f WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR W REPLACEMENT❑ Lines Pit Privy DISTANCE TO NEAREST: Septic Tank Sewer L } Sewage Disposal Field Cesspool/Seepage Pit - Other Property Lirie Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ IN DUSTRIAL :13CABLE TOOL Dia. of Well Excavation �w DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION .❑ GRAVEL PACK Depth of Grout Seal r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL. ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal installed By: PUMP INSTALLATION: Contractor � Type of Pump H.P.t 1 PUMP_REPLACEMENT: ❑ State Work Done PUMP REPAIR: 19 State Work Done 1- Approximate Depth !l DESTRUCTION OF WELL: Well Diameter f` 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:"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 Californiais 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 wil II fo a Gr Ins Ion prior to grouting and a final inspecti _ 7 Title: 4 Date: r� Signed X (Draw Plot Plan on Reverse Side) ' FOR DEPARTMENT USE ONLY PHASE I � �� Date Application Accepted By1,111111111, ,5,CAW a Additional Comments: 41 `n -gj Final IFispection Phase 11 Grout Inspection 'C/J' r�� Inspection By Date Inspection By Date Fee Is Due: C3 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH C1 January 1 &Received By January 31 ❑ July 1 &ReceivedJuly 31 REMIT REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION BILLING DATE DATE REMITTED AMOUNT FEE'.. 4 LESS PRORATION - PLUS PENALTY } OTHER y is OTHER 1 Issuance Date Mailed Delivered- Received by Dat Receipt No. Permit No. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16a1 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201