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Applications Will Be Processed When Submitted Properly Completed. Be Sur ign The Application. FOR OFFICE UAE: APPLICATI r�;� (For Non-Transfera�� 1 s ntl�abl �� PUMP&WELL ENVIRONMEN H LTH PERAMo (COMPLETE IN TRIPLICATE) WAT LIT3oN 2 0 �yy Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or'ntt 00,6,6rk herein described.This application is made in compliance ' h an in County a ce No. 1862 and the rules n � µi k ®er Joaquin Local Health District. Exact Site Address i p' ®it own Owner's Name Phone Address City r_ - Contractor's Name License Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation I rance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION WELL CHLORINATION 13 WELL ABANDONMENT 13 OTHER 13 PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ 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 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 Cl`j ❑ GEOPHYSICAL rlace Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done 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 hirin or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permra y hall employ persons subject to workman's compensation laws of California." I willu spection prior to grouting and a final inspection /� Signed X Title: Date: 1/7 ' �J (Draw Plot Plan on Reverse Sid F R D ARTMEN USE ONLY PHASEI 1) Application Accepted By Date Additional Comments: Phase I Grout Inspection Phase II� in nspection Inspection By �' Date Inspection By Date isco— Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. I suance D to Mailed Delivered f APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201