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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: // � APPLICATION fn„ L/ (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT G WATER QUALITY . (COMPLETE IN TR LICATE) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is made in compliance with San Joaquin County O dinance No. 186/and the rules and regulations of the San Joaquin Local Health District. Exact Site Address City/Town v Owner's-Name R. Phone r Address ty.... ` Contractor's Name r/ w Licerise# Business Phone Contractor's Address d Emergency Phone ' I. Is Certificate of Workman's Compensation Insurance on File With SJ HD? Yes No TYP11 E OF WORK (CHECK): 'NEW WELL El DEEPEN ❑. 'RECONDITION❑ DESTRUCTION[] WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Oa PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other i 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 r ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL` Sur a Seal Installe By: - PUMP INSTALLATION: Contractor - Type of Pump H.P. l/ PUMP REPLACEMENT: AL State Work Done PUMP REPAIR: ❑ State Work Done j DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I 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." I Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhichihis permit is issued, I shall employ persons subject to workman's compensation laws of California." s I ill call for a Grout Ins c'o rill r"io uting apda final inspection. Signed X itle: Date: (Draw MY Plan on Reverse Side) I FOR DEPARTMENT USE ONLY ' PHASE I r� '�/s� - J "- �Y _ 0 Z bate a: Application Accepted By Additional Comments: Pha a Grout Inspection ill t I Inspection Inspection By Date Inspection By Date " Fee IS Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 < REMIT BASE EXPLANATION BILLING REMITTANCE - 5 - AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION - PLUS PENALTY OTHER OTHER ti Received by Date Receipt No. Permit No, I�anc.DaMailed J .Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES N 1601 E.HAZELTON AVE.,P.O.Box 2409 STOCKTON,CA 95201 i-