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ApplicatioA"S"Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) ✓ ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE lN`TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This applieption is made in compliance with San Joaquin Co n y Ordigance No. 1862 and the rule and recii s f the San Joaquin Local Health istrict. Exact Site Address — SLIt[� Al �� I•y�/Town CZ�lJ Owner's Name lC 11!J Phone Address City 7�0 _ Contractor's Name License# 4" Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No + TYPE OF WORK (CHECK): NEW WELL, DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field 0(0� Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL r� 0 ❑ INDUSTRIAL ❑ CABLE TOOL pia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing e ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Informationz1a6 — ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure t 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. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall not employ an person in such manner as to become subject to workman's I P Y Y P I o man's compensaElan laws of California.' € Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will c II for a Groutpecti rior to grouting and a final inspection. Signed X Title: Date: (Draw PI Plan on Reverse ide) FOR DEPARTMENT USE ONLY PHASE ,Q Application Accepted Date Additional Comments. Phase II Grout Inspection Phase III Final Inspection i Inspection By _ Date Inspection By V Mm, Date "i � Z i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Or PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jufy 31 j REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ' DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER - I OTHER ' ceived by Date Receipt No. Permit No 1 Issuance Date Mailed Delivered i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 9520 (0-1. [ ..