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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) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is made in compliance with San Joaquin County Orspriance No. 6�2 and the rules and regulations of the Sanj aquln Local Health District. Exact Site Address � � J!f City/Town L_ 64-0 / fe-e-00. Owner's Name Phone Address — City Contractor's Nam ' License N;[_- &4/OL, Business Phone —_? 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❑ DESTRUCTION El WELL CHLORINATION 13 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 El INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1!1 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 n n ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor .� Type of Pump H.F. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done i 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 thework forwhich 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 for which this permit is issued, I shall employ person subject workman's compe ation laws of California." I wi all for a Grout Ingspjectio rior o grou -fig and a final ins ti n. Signed X Title: Date./ tt!rraw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY 7 PHASE C Application Accepted By Dat Additional Comments: Phase 11 Grout Inspection Phase Ul Final Inspection Inspection By Date Inspection By <1 Date ` Fee Is Due: 13ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 "LJ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DAMOUNT DUE CHECKED ATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER 4 I OTHER S-S--13 b 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 }