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A' Will B-Processed When Submitted Properly Completed:Be Sure ToSignTheAppucanon. -: APPLICATION FC�,rl OFFICE USE: endable) 4 (For Non-Traniferable, Revocable, Susp PUMP&WELL ENVIRONMENTAL HEALTH PERMIT " '� �'� � •� (COMPLETE IN TRIPLICATE) WATER QUALITY District permit to construct and/or install the work herein described.This applicati Application is hereby made to the San Joaquin on is Local Health Dism L� 1862 and the rules and regulati Clay/Tof the wnson Joaquin Local Health District made in compliance with San Joaquin County Ordinance No. ., .; Exact Site Address 8 Phone — Owner's Name City— Address ity ! Address - � Business Phone._r__�T� Contractor's Name License F 2 � Emergency Phone . ` Contractor's Address ^ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4-- No k TYPE OF WORK (CHECK): NEW WELL�DEEPEN�CONDITION❑ DESTRUCTION❑ i a 9--'PUMP REPAIR❑ WELL CHLORINATION ❑ WELL` ABANDONMENT OTHER ❑ PUMP INSTALLATION fa REPLACEMENT❑ 3 , �: 1'e-, Sewer Lines Pit Privy DISTANCE TO NEAREST: Septic Tank i Cess pool/Seepage Pit �®ej#' Other ' Sewage Disposal Field p Property Line Private Domestic Well Public Domestic Well INTENDED USETYPE OF WELL !! , ❑ INDUSTRIAL t ❑ CABLE TOOL Dia. of Well Excavation/ la'60MEST IC/PRIVATE ❑ DRILLED Dia. of Well Casing , ❑ DOMESTIC/PUBLIC ❑ DRIVEN '1 Gauge of Casing 1.2 ' ❑ IRRIGATIONS ❑ GRAVEL PACK Depth of Grout Seal _ .t 13 CATHODIC PROTECTION NARY Type of Grout OTHER x ❑ Other Information C3 DISPOSAL � Y Surface Seal Inst Iled By: 11 GEOPHYSICAL PUMP INSTALLATION: Contractor Type of Pump H.P.— �� PUMP REPLACEMENT: ❑ State Work Done ❑ State Work Done PUMP REPAIR: � o� � � App 'mate Depth DESTRUCTION OF WELL: Well Diameter ,�U ;_R/ Describe Mater I and Procedure I hereby certify that I haver 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. 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 for which this i permit is issued, I shall employ persons subject to workman's compensation laws of California.' k I will ll for a Grout Inspection prior to grouin and a final inspection. z;. I Signed X � .� Title: Date: {Draw Plot Plan an Reverse Side) FOR DEPARTMENT USE ONLY I PHASE I Date 9 • � � Application Accepted By Additional Comments: kk 7.TPhase/ll Grout Inspection .- � P s it Fin spectioWell- Inspection F. X f Date Inspection Date By- 1 - Fee Is Due' Cl ANNUALLY ❑ PER UNIT PER SITE ❑ EACH © January 1 8 Received By January 31 ❑ July 1 &Received By July 31 # REMIT BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT 11_61 FEE [f LESS PRORATION J- r PLUS -FT PENALTY r - OTHER 1 OTHER- ' Date Y ---I a . Receipt No. Permit No. issuance Date Mailed Delivered Received by 1 �+ 1fi01 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 � APPLICANTRETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES „.