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_ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (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 Joaquin Count Ordinance No. 1862 a d the les n ula ns of the San Joaqujn Local•He Ith District. Exact Site Address `��S �4'� bl ity/Town ��1 Owner's Name Re/*t �� V,Im a A 'd Phone 3 Address City F 7or J4 Contractor's Name License#5.51��1 Business Phone Contractor's Address 04y Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _xI No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONJ8 PUMP REPAIR El a REPLACEMENT❑ �. O DISTANCE TO NEAREST: Septic Tank 714" Sewer Lines Pit Privy Sewage Disposal Fieldfi�/� 24Cesspool/Seepage Pit Other Property Line/e r 'Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation J$,DOMESTIC/PRIVATE >tDRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing h ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 11CATHODIC PROTECTION A—ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information j� 11 GEOPHYSICAL S ace Seal Installed By: �� K PUMP INSTALLATION: Contractor � l � Type of Pump L° H.P. 3 PUMP REPLACEMENT: ❑ State Work Done1 PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 1 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I,will cal a Inspe tion prior to grouting and a final inspe / Signed X Title: a Date: �. (Draw Plot Plan on Reverse Sid FOR DEPARTMENT USE ONLY PHASEI Application Accepted By A Date Additional Comments: P ase 11 Grout Insectionn.� Phase III Final Inspection p Inspection By �� —f Date-gam, / ��5� c� Inspection By ate l'o?3 nD o Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE e� LESS PRORATION PLUS PENALTY OTHER OTHER 066 7,67 Received by Date Receipt No. Permit No. Issuance Date Mailed 'Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201