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l Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable,Revocable, Suspendable) � ' .-y- ENVIRONMENTAL HEALTH PERMIT PUMP&WE (COMPLETE IN TRIPLICATE) WATER QUALITY .a. Application iihereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This applicai:R� is made in compliance with Sari Joaquin County-Ordinance No. 7 62 and the ruleg ano r ulationsSan Joaquin Local Healt District. Exact Site Address tZY419%_`S Alh Owner's Name I Phone y Address City Contractor's Name License# 13; Business Phone Contractor's Address � -71016&1y Emergency Phone s—Qa,27/ Is Certificate of Workman's CompensationIn urance on File With SJLHD7 Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank �BQ Sewer Lines Pit Privy Sewage Disposal Field �(1Cesspool/Seepage Pit Other Property Line Private Domestic Well aW Public Domestic Well bQ INTENDED USE } TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing i ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 1.0 ❑ CATHODIC PROTECTION ROTARY Type of Grout ..... ❑ DISPOSAL ❑ OTHER Other Information _ ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done — N PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure ,I I 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. r� 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I wilt all for a Grout spec n prior to grouting and a final inspection. Signed X Title: Date: 41f (Dr Pot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By `^^^`� """ ` Date Additional Comments: 6-11. Phase 11 Grout Inspection Pha a 111 Final Inspection Inspection By Date �7 � Inspection By Date Al Fee 1s Due: ElANNUALLY ❑ PER UNIT 1-1PER SITE ❑ EACH ElJanuary 1 &Received By January 3 ❑ July 1 &Received By July 31 _� , BILLING REMITTANCE $F - REMIT �- .BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE ' CHECKED �] ' _ AMOUNT FEE LESS j PRORATION - PLUS PENALTY OTHER \ _t- OTHER Received by Dae- Receipt N Permit N -v Issu nce ate Mailed Delivered - x.w } APPLICA T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZEL'fCN AVE.,P.O.Box 2009 STOCKTON,CA 95201