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Applications Will Be Processed When Submitted Proper y omp letea FOR OFFICE USE: . � 'p APPLICATION Lp �m.o�aG� (For Non:Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMITj � WATER QUALITY (COMPLETE IN TRIPLICATE) quinLocalHealthDistrictforapermittoconstructand/or.installthework herein described.This application is Application is hereby made to the San Joa made in compliance with San Joaquin my Ordinance No. 1862 and the rules and regulations of the San Jo quin cai Health [7i�trir,.t` �} �. Z City/Town t(G� 4P2,,,— Exact � [[ Exact Site Address 11,11 1 Phone Owner's Name 1La City 4 Address ----------- License 'b Contractor's Name � #, i3..�1•�Business Phone Emergency Phone Contractor's Address No Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes— TYPE OF WORK (CHECK)`. NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION [3WELL ABANDONMENT 11OTHER E] PUMP INSTALLATION C1 PUMP REPAIR 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 TYPE OF WELL❑ CABLE INTENDED USE ❑ TRIAL TOOL Dia. of Well Excavation INDUS ' 11INDUS TIC/PRIVATE 11 DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC 13 DRIVEN ' Gauge of Casing IRRIGATION 11 GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: . PUMP INSTALLATION: Contractor 1 Type of Pump a !.e ✓= H.P....... 0 11 State Work Done PUMP REPLACEMENT: PUMP REPAIR: ® State Work Done Approximate Depth DESTRUCTION OF WELL: Well Diameter 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 ( 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 permit is issued, I shall employ persons subject to workman's compensation laws of California." I 1 call for a GrauI Ins e i p r o gro t g @td a final"inspection. e e: Date: Signed X (Draw Plat an on Reverse Side) FOR EPA RT ENT USE ONLY l PHASE 1 Date G Application Accepted By Additional Comments: Phase 111 Final lnspectio Phase 11 Grout Inspection f Inspection Inspection By Date By to -��fJ Fee IS Due' ❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING..1 REMITTANCE $ AMOUNT DUE CHECKED r BASE EXPLANATION DAT DATE REMITTED AMOUNT 3 f FEE LESS PRORATION If PLUS PENALTY OTHER OTHER _r Receipt No. - Permit No Issuance Date Mailed Delivered -Receivetlby Date 1601 E.HAZELTON AVE.,FLO,Box 2009 STOCKTON,CA 95201 APPLICANT—RETURN ALL_COPI9S TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - ��.