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Applications Will Be Processed When Submitted Properly Completed.Be SureToSign APPLICATION [FOR OFFICJUSE: -f - M (For Non-Transferable,Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) 4. WATER QUALITY M—%f Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is made in compliance with San Joaquin Count Ordinance No.1,862 and t e rules and regulations of the San Joaquin Local Health District. P City/Town Exact Site Address" - Phone Owner's Name City Address `- 3 I - - �- License# -S�. Business Phone'}' Contractor's Name h fi Emergency Pone Contractor's Address ' No Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes ,�, PU TYPE OF WORK {CHECK}: '" NEW WELL❑OONMENT ❑❑ OTHER 1TI N 11 PUMP MP-INSTALLAT ON DESTRUCTION! MP REPAIR❑ WELL CHLORINATION ❑ WELL ASA REPLACEMENT❑ - Pit Priv DISTANCE TO NEAREST: Septic Tank` Sewer Lines y • Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL. ❑ IND STRIAE ,� ❑ CABLE TOOL Dia. of Well Excavation -� ❑ DRILLED Dia. of Well Casing 1 & DOMESTIC/PRIVATE Gauge of Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN 12 IRRIGATION C3 GRAVEL PACK Depth of Grout Seal CATHODIC PROTECTION ❑ ROTARY Type of Grout 11 h i Other Information ❑ DISPOSAL 11 OTHER' ' ❑ GEOPHYSICAL r Surface Seal Installed By: Contractor PUMP INSTALLATION: ,..c. H P. Type of Pump IT❑ PUMP REPLACEMENT:' .State Work Da PUMP REPAIR: 11State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure. i I hereby certify that l have prepared this application and that the work will,be-done iri accordance with San Joaquin County I 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 O is issued, 1 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 b a Grout Inspe on prior to grouting and a final inspection. i l Title:. Signed X Date. / ~� (D�aw Plot Plan on Revrse Side) a FOR DEPARTMENT USE ONLY PHASE 1 Date x Application Accepted 8y ' G Additional Comments: W Phase II Grout Inspection Phase 111 at Inspection f Inspection By -Date Inspection By ate { Fee Is Due: ❑ ANNUALLY' ; ' ❑ PER UNIT El PER SITE -'❑ EACH C3Sanuary 1 R Received By January 31 Cl July 1 &ReceivedJuly 31 REMIT BILLING,; REMITTANCE $ AMOUNT DUE CHECKED .1 -- B-ASE EXPLANATDATE ION .DATE REMITTED AMOUNT - FEE LESS PRORATION PLUS PENALTY OTHER OTHER _' Date. Receipt No. Permit No. issuance Date ' Mailed De4ivered -Received by 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,F.