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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. !OICt FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) �— PUMP&WELL 0 op ENVIRONMENTAL HEALTH PERMIT WATER QUALITY O (COMPLETE IN TRIPLICATE) (q:-q,0V-,PJ - r4-�1iAkY t r - 0-3� Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is made in compliance with San Joaquin gount Ordinance No.1862 and the rules and regulations of the San Joa uin Local Health District. Exact Site Address ngedt _,"L_e4st e�J�t�CrrrsCity/Town C. e01 en Owner's Name CiV dAe .—CA4 1,9!/d Phone 91& - 3 3--?(NO Address 770,9 �@ City s� Contractor's Name J License# 3 Business Phone q3'�- IC4U Contractor's Address E Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_�_ No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION© DESTRUCTION❑ 1 j WELL CHLORINATION ❑ WELL ABANDONMENT El OTHER 11 PUMP INSTALLATION PUMP REPAIR❑ J REPLACEMENT❑ j DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy e Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL `I4_CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ; - ❑ DRI-L-LED—- ,- Dia..-of-Well Casing 044 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing or d/a 7`0- JR IRRIGATION ❑ GRAVEL-PACK -Depth of Grout-Seal �' r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout a ❑ DISPOSAL ❑ OTHER - Other Information ❑ GEOPHYSICAL Surface 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 I hereby certify that I have prepared this application and that the work will be done-M accordance with San Joaquin County .H and rules and regulations of the San Joaquin Localealth District. ordinances, state laws, g q _, 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." I Contractor's hiring or sub-contracting signature certifies the following:"I certify that:ih-the performance of the work forwhich this I permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspe n. Signed X c Title: _ r� �L ��`� Date: (Draw Plot Plan on Reverse Side) t F R DE ARTMENT USE ONLY PHASE I Application Accepted By Date 8 Additional Comments: E Phase II Grout Inspection �n Pha I Final I pection Inspection By - -- ---Date------- --/t7— -- - Inspection-By Date- Fee Is Due: 1:1ANNUALLY ❑ PER UNITY -..❑ PER SITE '❑t EACH— "10 January 1'&Received By January 31 " I]'July'1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE r LESS PRORATION PLUS PENALTY OTHER OTHER y /yt 1 b � 2 D �� 7 Received by D to Receipt No. Permit No- - Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 4 -