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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&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the worts herein described.This application is made in compliance with San Joaquin County Ordinance .N 1862 and the rules and regulations of the San Joaquin Local Health District. Ay A Exact Site Address 41 0EC2ArJK City/Town QV-ffd111 Owner's Name ' PhoneJ~ Address City Contractor's Name se# usiness Phone Licen ,. Contractor's Address _ Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONN WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ElPUMP INSTALLATION PUMP REPAIR❑ 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 T L Dia. of Well Excav 'on 13 DOMESTIC/ IVATE ❑ DRILL Dia. of Well C Ing ❑ DOMEST /PUBLIC ❑/R1 /eosing ❑ IRRIG ON L PACK ut Seal ❑ CA ODICPROTECTION ❑ Y t❑ D POSAL ❑ OTHER ation ❑ fOPHYSICAL M urfac eal Installed Val PUMP INSTALLATION: Contractor ! Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done fit PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure ft1 I hereby certify that 1 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." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 will II to a Grput I sp tion for to grouting and a final inspection. t Signed X Title: gamm".0 Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date -.---..— Additional Comments: Phase 11 Grout Inspection AMI.H.Final Inspection/Inspection By Date Inspection ByDate `o (6 Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received ey Date Receipt No. Permit No. IssTiance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .