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Applications Will Be Processed WhenSubmitted Properlycomplereo. oe aure Ioaiyn rnehl,Nr.4 ..,.,. FOR OFFICE USE, APPLICATION (For Non-Transferable, Revocable,Suspendable) pUMP&WELL (/ ENVIRONMENTAL HEALTH PERMIT -f' - (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 No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address cz---vem > I�t�. T City/Town Owner's Name n 1 Phone Address City Contractor's Name 1r1er��na,. l3noa Or.\�. � License Business Phone q!AS--j k% Contractor's Address 5- Emergency Phone -f kir Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes % No --5) " TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ •+ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank N60 Sewer Lines Pit Privy Sewage Disposal Field Lena--c Cesspool/Seepage Pit Other Property Liner Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation It} ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 19 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ®' GRAVEL PACK Depth of Grout Se ❑ CATHODIC PROTECTION ® ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information 11 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 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin I 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 thiis issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of CaliContractor's hiring or sub-contracting signature certifies the following:"I certify thatin the performanceof thework forw permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. Signed X � q^' rr'+'"�'-�_ Title: L) Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY t� PHASE I /i�% � e Date Application Accepted By Additional Comments: Phas ut Inspection Phase III Final/Inspection Inspection By Date �� Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By Jufy 31 REMIT BASF EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT EE 7, LESS PRORATION PLUS PENALTY OTHER OTHER %Yr 7 3 � Received by I 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 .'