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Applications Will Be Processed When Submitted Properly CompletegIS6) Sign The Application. FOR OFFICE USE: APPLICATI Sti�(For Non-Transferable, bS pehe PUMP&WELL ENVIRONME y M LTH PER ; (COMPLETE IN TRIPLICATE) WA UAu3 \_ Application is hereby made to the San Joaquin Local Health District fora rmitto c nstruct an i�50H ,work herein described.This application is made in compliance with San Joa in ty Ordi ante No. 1862 and the rules andtri� lxtatj [Ls1� a Joaquin L cal ealth District Exact Site Address 7 �N �Ity/Town Owner's Name � '�"`f� H Phone Address City Contractor's Name License#�r��.� 7-3 Business Phone Contractor's Address ' Emergency PhoneL76r,(^ 7 re t Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �-- TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION © PUMP REPAIR REPLACEMENT❑ w DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property LiPe Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation © 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 ❑ GEOPHYSICAL y� S rface Seal Installed By: PUMP INSTALLATION: Contractor N Type of Pump T_ �,�r-�-�s�L H.P. PUMP REPLACEMENT- -StateWork Done' PUMP REPAIR: estate Workbone 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. 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 permit is issued, I shall employ persons subject to workman's compensation laws of California." I w' II f r a Grout Ins ection�togroufin' and afinal ins ;ction. 7 �r Signed X Title: Dater �. (_Dve raw Plot Plan on Rer Side) I� FOR DARTME USE ONLY PHASE I ry f�G Application Accepted By-��///'' �'�` o JI- D to / - Additional Comments: Phase II Grout Inspection he III Fina s on Inspection By Date Inspection f Date E Fee Is Due: El ANNUALLY [-1PER UNIT PER SITE Cl EACH ❑ January 1 &Received By uary 31 ❑ July t &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED dl DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY I OTHER OTHER h 673aa- 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