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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 INT IPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application.is made in compliance with San Joaquin Coun y rdinance No. 862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address �_ � Ah 1,g _—� City/Town C le-2 A4ov Owner's Name ��LF_SW /f ivin Phone '_, Address 0 y City Contractor's Name License# ,?� %/ Business Phone Contractor's Address Emergency Phone n Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ X __ No TYPE OF WORK (CHECK): NEW WELL,9 DEEPEN El RECONDITION 11DESTRUCTION❑ WELL CHLORINATION El WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ i i DISTANCE TO NEAREST: Septic Tank -E- Sewer Lines Pit Privy Sewage Disposal Field�%r�Q !$ Cesspool/Seepage Pit — Other — Property Line 10 Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL tr ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation1' ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Z r DOMESTIC/PUBLIC Ir❑x DRIVEN Gauge of Casing ❑ IRRIGATION lAt GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout c��F�d ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. !w PUMP REPLACEMENT: El State Work Done vl 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." I will call for a G ut In ctio or to grouting and a final inspection. Signed X Title: ,E iD E/*'L Date:zc I 146,t (Draw Plot Plan on Revers ide) FOR EPARTMENT USE ONLY PHASEI /.J Application Accepted By Date y 0 Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By Date 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 3 �� ✓ LESS PRORATION PLUS PENALTY OTHER OTHER ��C Received by Date Receipt No. Permit No. Issuance Ivate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520