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Applications Will Be Processed When Submitted Properly Completed. Be°Sure=To Sign The Application. FOR OFFICE USE: APPLICATION © � (For Non-Transferable, Revocable, Suspendable)_. Q PUMPfjal 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 compliance with San Joaquin.County Ordinance 0..1862 and the rules.and regulations of the San Joaquin Local Health District. Exact Site Address 1 City/TownE }�pyL,c. Owner's Name "� � - - Phone Address 14 J City ' " Contractor's Name ;]�� ic "`' License# '`C� BiJsiness Phone 23 Contractor's Address 12Emergency Phone: " Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ " PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other 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 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL - Surface Seal Installed By: PUMP INSTALLATION: Contractor ":- Type of Pump H.P. s PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: State Work Done_ fie" DESTRUCTION OF WELL: { Well Diameter Approximate Depth 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. Homeowner 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 will call for a Gr Inspection prior to grouting and a final Inspection. Signed X Title: i G .r-r� Date: ; (Draw Plot Pian on Reverse Side) FOR DEPARTMENT USE ONLY 1 PHASE Appli atlion"Accepted"By 10- Ll `—" i1 Date Additional Comments:- A Phase II Grout Inspection Phase III Final Inspection 12 7 � —&4Inspection By Date inspection By Date b Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT' ❑ PER SITE "❑ EACH ❑ January"'I &Received By January 31 ❑ July 1 &Received By July 31 REMIT ' BILLING REMITTANCE $ BASE EXPLANATION DATE DATE AMOUNT DUE CHECKED REMITTED s AMOUNT FEE l� B LESS •{� PRORATION PLUS PENALTY OTHER OTHER Received by Oate Receipt No - Permit No.- Issuancd Date Mailed - Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 )