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Applications Will B+,-Processed When Submitted Property Completed. Be SureToSignTneAppncauon. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL 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 compliant wit San Joa�uin County Ordinance No. 1862 and th ru d regulations of the San Joa, in Local Health District. Exact Site Address 41, ity/Town /�c r4�.v - Owner's Name - '�; �!� Phone Address 5 City Contractor's Name k icense#_? !I S! Business one Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION C1 DESTRUCTION❑ p WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ f I A' DISTANCE TO NEAREST: Septic Tankes __ � � Pit Privy = �) Se age Dispoa�Fiel�d��sCesspool/S eepage Pit -_ Other Property Line_/0 47: Private Domestic Well S4 l Public Domestic Well INTENDED USE TYPE OF WELL +i ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation Lr C3DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing _ 13DOMESTIC/PUBLIC El DRIVEN Gauge of Casing t IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal E ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: oe3 1AJ A(If 02 PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT:. i ; ❑ State Work Done PUMP REPAIR: ❑ State Work Done i DESTRUCTION OF WELL: Well Diameter Approximate Depth F Describe Material and Procedure I I hereby certify that I have prepared this application and that the work will be done in 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 , is issued, I shall not ismploy any person in such manner as to become subject to workman's compensation laws of California Contractor's hiring or,sub-contracting sl ture certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall em y per n ubject to workman's compensation laws of California." I wit ro Ins tion o grouting and a final inspection. f Signed X It Title: DateA :7_7"A, 0 (Draw Plot Plan onReverse ide) Y FOR DEPARTMENT USE ONLY . i PHASE 1 Application Accepted By �"^" Date U Additional Comments:_1 Plisse II Grout Inspection flyase III Final Inspection �n Inspection By ;I� Date Inspection Date Fee Is Due: ❑ ANNUALLY ' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 I!' BILLING REMITTANCE $ REMiT BASE EXPLANATION AMOUNT DUE CHECKED d� DATE DATE REMITTED AMOUNT FEE . —t�J LESS I� PRORATION - PLUS PENALTY OTHER �I OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON.CA 95201 In In Ii