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� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOIA OFPtCE USE: APPLICATION I (For Nan-Transfera6le, Revocable,Suspendable) � PUMP&Wi^L1. -ENVIRONMENTAL HEALTH PERMIT r (COMPLETE IN TRIPLICATE) WATER QUALITY I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework herein described.This application is made in compliance with San J quin County Or inanr No. 1862 and the rules and regulations of the San JoagWn.Local Health District. f Exact Site Address � - City/Town 64 � Owner's Name Phone 9A 3 3 00 Address City��.—.. �°" Contractor's Name License# Business Phone Contractor's Address Emergency Phone 1 �S Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes No �j TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ e WELL CHLORINATION ❑ 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 LineJ�J7__ Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL j 4 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation r 14 DOMESTIC/PRIVATE DRILLED Dia. of Well Casing L I C] DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ` ❑ CATHODIC PROTECTION ROTARY Type of Grout c I ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: Q �� c PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done ! El State Work Done PUMP REPAIR: � 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 SanJoaquin 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 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 will call k for/a Grout Inspection Inspection prior to grouting and a final inspection.Signed X e , G.�r' �'�p�� Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY I PHASE I A. i Application Accepted / Date Additional Comments: Phase 11 Grout 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 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DANE DATE REMVTTED ,( AMOUNT FEE 4Y,` LESS PRORATION PLUS t PENALTY r OTHER OTHER J R Received by Date Receipt No. Permit No, Issu nce Date Mailed Delivered - STOCKTON;CA 95 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICE5 1601 E.HAZELTON'AVE.,P.O.Box 2009 .