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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFF CE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) O CQ.UALITY 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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address XO/ 'A CAK C,9.SXK 1, Acwgw CouR`T City/Town 5M0---&TQ/Al Owner's Name ZIr4.'7-.4 � /s [�P/;1 15 M% Phone 9?.Sf C? .3 y Address p0• &"c 74y/y City _S7tc./r7-*A/ Contractor's Name AlO. G k P&m P License#366-A/3 Business Phone ?409— Contractor's Address 1f.�0 /�• A_R&_M owT 57, Emergency Phone 4 W ^$�/7 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IX 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 RN ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �f ®[ 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 ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor NO AC A U A4 P Type of Pump I gM F/aSi Bhp 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. 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." 1 will c I for a Grout Insp ctt rior to groutjng and a final inspection. Signed X Title: Date: (Draw Plot Plan on Reverse Side) FO DEPARTMENT USE ONLY A/OTE = TNhf AKA" 7 " -r?vC-"s- PHASE I 4-<-'—' Application Accepted By I Date Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By Date 34 Z Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. l4suance l3ate, Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201