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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (Far Non-Transferable, Revocable,Suspendable) PUMP&WELLENVIRONMENTAL HEALTH PERMIT (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 San Joaqui�Founty Ordin ce No. 1862 ani the ru nand regu do f the San Joaquin Local Health District. Exact Site Address�'t 1��-fa�1�r� �r� f�C2(p d ca RC1 � 1 own Owner's Name �'Sr` Phone .- Address Contractor's Nam License#3Cod 97,4-,/ Business Phone 7-- o Contractor's Address jr cy Phone �y — 3 9 y Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL S— DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION &— PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit P �JJ Sewage Disposal Field Cesspool/Seepage Pit Other_1,1-01 Property Line -- Private Domestic Well - Public Domestic Well --� INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 3`UO-MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATIONr- ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION 0-90TARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: ' PUMP INSTALLATION: Contractor Type of Pump cif-iii H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure Y 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. 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 ermit is issued, 1 shall employ person bject to workman's compensation laws of California," I 'it call for a Grout Ins e i n gro ling and a final inspection. Sig Title: �SZ _/�_ ZM G .n Dale: 19 raw Plot Plan on Reverse Side) - t FOR DEPARTMENT USE ONLY EI Application Accepted By � .. Date3-17, Additional Comments: 07 - is se II tG-rro Inspectionhase� Final inspection Inspection By U 5d Inspection By Date y Fee Is Due: ❑ AN NU LLY 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 1 r LESS PRORATION PLUS PENALTY OTHER OTHER . Received by ..Date Receipt No ,Permit No, Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES ., '1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 '{ ',