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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. in FOR OFFICE USE, APPLICATION (For Non-Translerable, Revocable, Suspendable) PUMP&WELL- i ENVIRONMENTAL HEALTH PERMIT " WATER QUALITY ' (COMPLETE IN TRIPLICATE) , Applicatio.9 is hereby made to the San Joaquin Local Health District fora,permittoconstruct and/or install the work herein described.This application is made in co',IIpliance with San Joagyin county Ordinance No.1862 and the rr les and reguljpt_ions of the San Joaquin Local Health Dijtrict. Exact Site Address / �1E'��uf, 1� — ��' EC1S�aT x/21 44 City/Town 170��T�'] .SII J Owner's Name Phone Address J' City Contractor's NameNlll�Jlil fixe License# 1;2�._?'j3 Business Phone Contractor's Address es ICL r� P. ,/��I�PS Emergency Phone3 � 71 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes kNo TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ / DISTANCE TO NEAREST: Septic Tank av 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 / DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing uZ?e _-- ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout r ❑ 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 1 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 wit call for a Grout Inspects n prior to grouting nd a final inspection. Signed X Title: Date: (Draw PI Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By O� Date ! �' Additional Comments: Pha 1 out InspectionSf Phase 111 Final Inspection Inspection By Date Inspection By 1J Date 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 AMOUNTDUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS v PRORATION PLUS PENALTY OTHER OTHER L 76 Received by Date I Receipt No. Permit No. - Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES _d 1601 E-HAZELTON AVE.,P.O.Box 2009 STOCKTON,.CA 95201 'i},