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Applications Will Be.Processed When Submitted Properly Completed. Be Sure ToSignTheApplicanon. A FOR OFFICE USE: APPLICATIONL4 /v 0�� (For Non-Transferable, Revocable,'Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT WATER QUALITY..; (COMPLETE IN TRIPLICATE) ., 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 an Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address City/Town Phone _ Owner's Name jr, 011 s 'City Address License# � Business Phone ' Contractor's Name n "'EmergencylPhorie Contractor's Address '} Is Certificate of Workman's Compensation_ Insurance on File With SJLHD? Yes _ No TYPE OF WORK (CHECK): NEW WELL El. DEEPEN ❑ RECONDITION❑� DESTRUCTION WELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER 13PUMP INSTALLATION 2 PUMP REPAIR❑ , REPLACEMENT❑ • i 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 ❑��I �STRIAL 11 CABLE TOOL Dia. f Well Excavation E DOMESTIC/PRIVATE ❑ DRILLED Dia. of ell Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: �?� PUMP INSTALLATION: Contractor h21 �. Type of Pump _ 1=4 ,'' H.P. PUMP REPLACEMENT ❑ State Work Done 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. 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." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this per is issued, 1 shall employ persons subject to workman's compensation laws of California." I will?029a Grout I spection prior to-grouting and A final inspection. _ x. Title: tom_ Date: 3' � Signed (Draw Plot Plan on Reverse Side) ; FOR DEPARTMENT USE ONLY ' / r PHASE I Application Accepted By i -"F -— Date - Additional Comments: Phase II�Grout 4nspectlon �T Pf s I Final Inspection Date Inspection By kDate Inspection By -- Fee Is-Due: IJANNUALLY PER UNIT ;' ❑ PER SITE ❑ EACH ❑ January 1 &Received By January'31 ❑ July 1 &Received By July 31 REMIT _ ' ` --EXPLANATION BILLING_ REMITTANCE --$ - AMOUNT DUE CHECKED BASE ` j DATE DATE REMITTED AMOUNT ~FE ` E. •"'T 5 LESS PRORATION PLUS - PENALTY OTHER OTHER Received by Date - Receipt No.'. ,Permit No. Is uance bate I- Mailed- -.Delivered= - -- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201