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I Applications Will Be Processed When Suomi ted-Properly Completed. Be Sure To Sign The Application. }— FOR oFlFiii usE; :APPLICATION -y-= (For NortLTransferable, Revocable, Suspendable) - PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Locai ,,alth District fora permit to construct and/or install the work herein described.This application made in compliance with San Joaquin County Ordinance No. 1462 and the rules and regulations of the San Joaqui Local ealth District. Exact Site Address . - City/Town -9 Owner's Name a r Address... Phone VA� -.,,.- ' City. Contractor's Name .y 0i nse# -) Business Phone .- 1 Contractor's Address -191/,t 'C�L1�L�.cl,� slr _ Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No f TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR ElREPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank r Sewer Lines l - Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Property Line Private Domestic Well Public Domestic Well Other INTENDED USE TYPE OF WELL J ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation rr O`DOMESTIC/PRIVATE ❑ DRILLEpDi a. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN 11IRRIGATION Gauge of Casing 1d GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION MEROTARY 11DISPOSAL Type of Grout ❑ OTHER Other Information ❑ GEOPHYSICAL PUMP INSTALLATION: Contractor Surface Seal Installed By: r ' Type of Pump PUMP REPLACEMENT: ❑ H.P, - State Work Done PUMP REPAIR; ❑ State Work Done !elr DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 0 r 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. Homeowner or licensed agent's signature certifies the following:1 certify that in the performance of the work for which this permit f€ 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection pri r to routing and a final inspection. Signed X Title: Date: tis (Draw Plot Plan on Reverse Side) PHASEI FOR DEPARTMENT USE ONLY Application Accepted By - Additional Comments: Date Z P729,!h II Grout Inspection se in� Inspection Inspection By Date Z' Inspection g P Date Fee Is Due: ❑ ANNUALLY 5 PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1 &Received B Januar _ - Y Y 31 El July 1 &Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE REMITTED AMOUNT OUE CHECKED FEE �'$� AMOUNT LESS PRORATION PLUS PENALTY t OTHER OTHER a Receivetl by Date 5 � �� Receipt No. - Permit No. I suance Date Mailetl -� APPLICANT—RETURN ALL CQpIES TO: ENVIRONMENTAL HEALTH PERM17/SERVICES Delivered 1601 E.HAZELTON AYE.,p.0:Bo:2009 STOCKTON,CA 95201 � .