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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplicailion. ; FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY { �� n , ,. ,.,� cH.fir"lE4. ' i Application is hereby made to the San Joaquin Local Health District for a pe}mif}to construct and/or IristalI the work herein described.This application is made in compliance with San Joaquin ounty Ordinance No. 188q.2,and the rules and reQ'igulations ofs he San JoaquinTLoca1 Health District. r Exact Site Address �-- City/Town , l 0. Owner's Name Ph'one-i G Address S .t y :e,a w.. ## 'rM, .� we of a•�c City''. Contractor's Name License k33lrsor , Business-Phone �] ! Contractor's AddressEmergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes V� No y TYPE OF WORK-(CHECK):" NEW WELL 13 -DEEPEN ❑ - RECONDITION IT DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ f 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 k ❑ IN STRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑-GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 11 DISPOSAL' ❑ OTHER Other Information ❑ GEOPHYSICALContractor Surface Sea] Installed.By: PUMP INSTALLATION: s - _ Type of Pump—�L�J�'� : H.P. PUMP REPLACEMENT: ❑ State Work Done..__. i PUMP REPAIR: ❑ State Work Done 6 DESTRUCTION OF WELL: Well Diameter y _Approximate Depth l."xDesc ibe Material and Procedure `'I hereby certify that I have prepared this application and that the work will tie done in accordance with San Joaquin Counordinances, 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 thework forwhich this permi. is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California Contractor's Ihiring or sub-contracting signature certifies the following!1 certify that in the performance of the work forwhich this r permit is issued. I shall employ persons subject to workman's compensation laws of Caifornia." I will Cal a Grout Inspection prior to.grouting and a final inspection. -- —i ' + 9 ! Sign ' Title: �r 1'ul—._�' Date: -- { ' (Draw Plot Pian on Reverse Side) k s { _t FOR DEPARTMENT USE ONLY PHASE 1 Application Accepted By Date,— Additional Comments: ! Phase 11 Grout Inspection Phas II nal Inspectibn��.D� �� Inspection By Date Inspection By Date. - Fee Is DUB:-❑ ANNUALLY"�"❑ PER-UNITT�°�'--❑'PER SITE-' '❑'-EACH' ❑-January�l &Received By January 31 ❑ July 1 &Received By July-31 REMIT - BASE ExPLANATION - .BILLING REMITTANCE _ _ $ AMOUNT DUE CHECKED DATE BATE REMITTED AMOUNT k[ LESS PRORATION 4 PLUS PENALTY t OTHER OTHER r . .� - , lilt -J ]� .• _; -- i Received by - Date - Receipt No.' _-r Permit.NVoo. - - !_ Issua a Date Mailed. ., Delivered ;, T_ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201