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[FOR ppima ionswill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. 1?FFfcE USE: APPLICATION L*'00'6N fa a (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH .PERMIT PUMP&WELL . (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 Joagyin ounty Ordinance No. 1862 and the rules and regulati of the San Joaquin Local Health District. Exact site Address d 6 /Y a, �/4 (j wL::ty/Town Owner's Name OJ�t Address Phone Contractor's Name City �� " License# l 7a.- Contractor's Address a. � M — -��Business Phone,- Emergency Phone ) Is Certificate of Workman's Compensation Insurance o r SJLHD? Yes -- No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 5dREPLACEMENT PUMP REPAIR ❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL ❑ DOMESTIC/PRIVATE � Dia. of Wel! Excavation ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN IRRIGATION Gauge of Casing ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY 11DISPOSAL Type of Grout ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Sealinstalled By: PUMP INSTALLATION: Contractor I Type of Pump H P r 4. PUMP REPLACEMENT: 99 State Work Done PUMP REPAIR: IJState Work Done DESTRUCTION OF WELL: Well Diameter ' Approximate Depth Describe Material and Procedure r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state Iaws, 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 taws 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." t (�I w I call for a Grout Inspectio no ro nand a final inspection. Signed itle: Date: (Draw Piot Ian on Reverse Side) — PHASE I FOR DEPARTMENT USE ONLY �(1(\ Application Accepted By Additional Comments: Date ' Phase 11 Grout Inspection Phase III Final Inspection Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 13 EACH ❑ January 1 &Received By January 31 ❑ .tiny 1 &Received By July 31 BASE EXPLANATION BILLING REMITTANCE REMIT DATE DATE REMITTED AMOUNT DUE CFIECKED FEE AMOUNT LESS PRORATION ' PLUS �"� ✓ PENALTY OTHER OTHER Received by Date Receipt No �Permit I suanc Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMFT/SERVICES — 1001 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201