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Applications Will Be Processed When Submitted Properly Completed. BeSureTobign IneAPPIIGUIIUIT- FOR G'FFICE USE: APPLICATION (For Non-Transferable, Revocable;Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY n,,..,.� Appiication is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San 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 Address t City Z _ 1 Contractor's Name License fit�`�� Business Phoneme rj Contractor's Address Emergency Phone' Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO�NO WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER El PUMP INSTALLATION L PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy a Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ STRIAL ❑ CABLE TOOL Dia. of Well Excavation - I� MESTIC/PRIVATE ❑ DRILLED Dia. of Well.Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY r Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL f Surface Seal installed By: _ F PUMP INSTALLATION: Contractor Type of Pumper H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done 1�1 -- DESTRUCTION OF WELL: t 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 ti 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." 1 will f GI It I ection prior to grouting and a final inspection. Signed X Title: t5:�=1/1-9 _ Date: € (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date Additional Comments: Phase II Grout Inspection It Final Inspection Inspection By Date Inspection By �/ ]ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑/July 1 &ReceivedREMITuly 31 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE - CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Data -• Receipt,No.- - Permit No.- illssuanceD ate Mailed Delivered ti. 1601 E.HAZELTON AVE.,P.O.Bol 2099 STOCKTON,CA 95201 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERViCES