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.�. :.:.. Applications Will Be Processed When Submitted Properly Completed. Bebure FOR OFFICE USE: APPLICATION , (For Non-Transferable, Revocable, Suspendable) PUMP &WELL ENVIRONMENTAL HEALTH PERMIT WATER QUALITY = - L��ATE) Application is hereby made to the San Joaquin Local-Health District for apermit toconstruct and/or installtheworkherein described.Thisappiicationis made in compliance with San Joaquin County Ordinan e o.1862 and t rules and regulations of the San Joaquin Local Health District. 21 P11City/Town (-`� Exact Site Address —� Phone r; Owner's Name City Address Contractor's Name CLicense Business Phone_ It Emergency Phone Contractor's Address �/ No Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1 i TYPE OF WORE( (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 7" WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR REPLACEMENT❑ ` - Sewer Lines Pit Privy DISTANCE TO NEAREST: Septic Tank Other Sewage Disposal Field Cesspool/Seepage Pit Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL �• El INDUSTRIAL C3 CABLE TOOL Dia. of Well Excavation }# ' ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i 11 IRRIGATION 13GRAVEL PACK Depth of Grout Seal +- 11CATHODIC PROTECTION C] ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information �[ Surface Seal Installed By: ❑ GEOPHYSICAL , PUMP INSTALLATION: Contractor ' H.P. Type of Pump PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: State Work Done' owl th DESTRUCTION OF WELL: Well Diameter Ap��f Describe Mater'all a d Procedure I hereby certify that I have prepared this application and that the ork will be done in a ordanc with San Joaquin County k 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 forwhich this permit r 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 I will c 1 for a Gr ut Inspection prior to grouting and a final inspecti Title: Date: Ce Signed X Y� (Draw Plot Plan on Rev rse Sid ) FOR DEPARTMENT USE ONLY PHASE I �, 3 Date Application Accepted By Additional Comments: Phase II Grout Inspection Ph se III Final Inspection 1 Inspection By Date Inspection By Date Fee IS Due: C3 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 [3 July 1 &ReceiveR MlTd By uly 31 - BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER I OTHER I suance Mailed -Re eived try Date Receipt No Permit No Delivered CKT - .� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C4.95201