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Applications Wilt-Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. FOR OFFICE USE: ( APPLICATION [ } (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL, (COMPLETE IN TRIPLICATE) (/Y�, QU�LITY I/f{ J c �� Application is hereby made tothe San Joa ealthDistrictfo apermittbconsirtfctandlorinstallt work herein described.Thisapplicationis made in compliance wit LSan Joaqui Coun diaiance N 186?a he rules and regulations of the SanoJfaquin Local Health District. Exact Site Address t City/Town Owner's Name Phone Address r Cit Of v Contractor's Name a icense# Bu ' ess Phone�a Contractor's Address mergency Phone Is Certificate of Workman's Compensation Insu ce on File With SJLHD9 Yes No TYPE OF WORK (CHECK): NEW WELL Er DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONM NT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ ll� 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 I)WE OF WELL ? ❑ INDUSTRIAL 10/CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing U-'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Ae_ ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H P PUMP REPLACEMENT: ❑ State Work Done „o PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter4- Approximate Depth Describe Material and Procedure ee I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1. 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." �t I will for a Grout Insp n pri r to grouting and a final insppee tion. C Signed X -�?✓� Title: Date�?� � � raw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By — � Date Additional Comments: Phase II Grout Inspection Phase 1 i a_I Inspection Inspection By Date Inspection By Date &Pq1V_ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rece, d By January 31 ❑ July 1&Received By July 31 BILLING REMITTANCE REMIT BASE EXPLANATION $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE o� LESS PRORATION PLUS PENALTY OTHER OTHER Received byDate Receipt No. Permit No. y � Issuance .ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201