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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR O FICE USE: // APPLICATION Cp H G6 (For Non-Transferable-, Revocable ,Suspendable) PUMP&WELL �' I I 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 County Oance No. 1862 and the r Yles'and a ul tions of the San Joaquin Local Health District. Exact Site Address r 5040. rdi 1 .k), City/Town Owner's Name Phone Address se_- i.. City Contractor's Nam "`'License#11.3-Nmr—Business Phone G Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With eJLHD? Yes X No TYPE�OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ !RECONDITION❑ -- DESTRUCTION❑ Q WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 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 i ❑ DOMESTIC/PRIVATE ❑ DRILLED I Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal `z ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL 6� Surface Seal Installed c PUMP INSTALLATION: Contractor Type of Pump AL H.P. 06 " PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ® State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure ` s F 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." t Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this A permit is issued;l'shall employ persons subject to workman's compensation laws of California." CA ill all for a Grout Inspec n~Lw p io groutin a al inspec i� Signed : Date: w. (Draw PIoYPI on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I 4;14 a. Application Accepted By v Date i Additional Comments. Phase II Grout Inspection 7Phal final Inspection Inspection By ►ft Date Inspection By ,; Date Fee Is Due: ❑ ANNUALLY ETPER UNIT ❑ PER SITE ❑ EACH "❑ January 1'&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 C OTHER OTHER j Received by- Date Receipt No. - Permit No. suance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ' 7