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Applications Will 13e Processed When Submitted Properly Completed. Be Sure To Sign The Application. - FOR OFFICE USE: APPLICATION A-/04J_ (For Non-Transferable, Revocable, Suspendable) 5AW �� `y ENVIRONMENTAL HEALTHPERMIT PUMP&WELL•- (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 186 and the rules a d regulations of the San Joaquin o I Health District. l Exact Site Address l� Z-3 �Q City/Town Owner's Name, /�'^ / G � i,( ��\ Phone Address e 'Y - City � / Contractor's Name License# j_7!i _Business Phone -—� 7 G -G Contractor's Address Emergency Phone a Is Certificate of Workman's Compensation Insurance on File With LHD? Yes __ _ No 77 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION© DESTRUCTION❑ WELL CHLORINATION ❑ - WELL ABANDONMENT ❑ -OTHER ❑ PUMP INSTALLATIONE]. 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 TOOL Dia. of Well Excavation a ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing y IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal N t E3 CATHODIC PROTECTION E] ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL ; r Surface Seal Install By: PUMP INSTALLATION: Contractor e " Type of Pump ®.G-✓ H.P. PUMP REPLACEMENT: ❑ State Work Done- PUMP REPAIR: ER State Work Done' 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 j 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 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 will call for a Grout Inspection priorg A�iand inal insp ti r Signed X �� T111e: Ow Date: f (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By Date/M -77 Additional Comments: Phase Il Grout Inspection Phase.11t Final IIn�spe�c�n Inspection By Date Inspection Fee IS Due: ❑ ANNUALLY [__1 PER UNIT ❑:PER SITE EACH 11 January 1 8.Received By.January 31 ❑ Juky 1 &Received By July 31 BILLING REMITTANCE -$ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE - LESS PRORATION 0 PLUS PENALTY OTHER OTHER CZ -71 Received by .Date Receipt No Permit No. - Issuance Date Mailed Delivered ..... '' APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTi P.O.Boa 2009 STOCKTON,CA 95201' ,`�