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Applications Will Be Processed When Submi(ted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL U + ENVIRONMENTAL HEALTH PERMIT li WATER QUALITY (COMPLETE IN TRIPLICATE) 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 No. 1862 and the rules and regulations of the Sap Joaquin Local Health District. Exact Site Address AJ 14,'1 City/Town Owner's Name Phone 4- Address � City I na � Contractor's Name License#I IL::3iBusiness Phone 7 YS r Contractor'sAae Emergency Phone Is Certificate of Workmans Compensation Insurance on File With SJLHD? Yes No q TYPE OF WORK (CHECK): NEW WELL97-�DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ 5 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION-Q— PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Cts Sewer Lines &; Pit Privy 1� Sewage Disposal Field Cesspool/Seepage Pit Other I Property'Line Private Domestic Well # ' Public�Domestic Well INTENDED USE ��-'�t TYPE OF WELL t ❑ INDUSTRIAL ❑-CABLE TOOL Dia. of Well Excavation g-80MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �. b k ❑ CATHODIC PROTECTION NARY Type of Grout __-7 ❑ DISPOSAL 11 OTHER Other Information 11e ea GEOPHYSICAL Surfacl Installed By: PUMP INSTALLATION: Contractor Type of Pump �e's�`• " H.P,, PUMP REPLACEMENT: ❑ State Work Done . t PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter '' Approximate Depth C Describe Material and Procedure I hereby dertify that I have prepared this application and,that the work will be done in accordance with San Joaquin County p 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 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,'1 `shall employ persons subject tot workman's compensation laws of California." E. I will call fora Qroyt Inspection pr'or to grouting and a final inspection. �J L Signed X Title: 12- Date. cL_% � s� ' (Draw Plot Pian on Reverse Side) J e • r FOR DEPARTMENT USE ONLY f PHASE I Application Accepted By Date Additional Comments: 1 3 P Grout Inflection Phase III Final P spection Inspection By / ate ! r Inspection By Date r / Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ! July 1 &Received By July 31 REMIT BILL{NG REMITTANCE $ S BASE EXPLANATION DATE DATE REMITTED AMOVNT DUE CHECKER AMOUNT FEE ��_ 4�Y7•D DC7 V QQ 00 LESS PRORATION i PLUS PENALTY I' OTHER 1,91 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.D.Box 2009 STOCKTON,CA 95201