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,.e• �.�. �....rrr • Applications WIEI Be Processed When Submitted Properly omp e F OR USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT 4 WATER QUALITY , (COMPLETE IN TRIPLICATE) ' Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittaconstructand/arinstalltheworkhereindescribed.This.applicationls � made in compliance with S �oa uin Gount finance No.1862 and thes nd regulations of the Sagf 'ocy�l Heal j City/Town / 1 Exact Site Addres f f Phone Owner's Name City Address y Contractor's Name Licens Business Phone Contractor's Address Emergency Pho e Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL V DEEPEN❑❑ RECONDITION ON ITIOPU❑ DESTRUCTIONMP INSTALLATION ❑❑ PUMP REPAIR❑ WELL CHLORINATION ❑ WELL ABANDONMENT OT REPLACEMENT❑ : 1 DISTANCE TO NEAREST: Septic Tank �er Lines Pit Privy.�Q-� Other Sewage Disposal Field Cesspool/Seepage Pit Z , I ' Private Domestic Weil�"-public Domestic Well_ d k Property Lin INTENDED USE TYPE OF WELL /Y ❑ INDUSTRIAL 11CABLE TOOL Dia. of Well Excavation ?� OMESTIC/PRIVATE DRILLED Dia. of Well Casing QDOMESTIC/PUBLIC DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Type of Grout ❑ CATHODIC PROTECTION ROTARY yp00, [` 11 DISPOSAL OTHER Other lnformatio E ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor H.P. Type of Pump PUMP REPLACEMENT: ❑ State Work Done I PUMP REPAIR: C1State Work Done Approximate Depth DESTRUCTION OF WELL: Well Diameter F Describe Material and Procedure I hereby certify that 1 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. a 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:1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I i� for G ion prior to grouting and'a final inspection. T'I�e: , A ate: Signed X (Draw Plot Plan on Reverse fide) FOR DEPARTMENT USE ONLY PHASE 1'& �C/ Date I Application Accepted By Z / Additional Comments: P as 11 Grout Inspection a e III Final InsDate Inspection By i Inspection BY Date � ~ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH C3 January-i &Received By January 31 July 1 &Received REMIT 31 6SLLING REMITTANCE AMOUNT DUE CHECKED r BASE EXPLANATION DATE DATE REMITTED AMOUNT = 043 FEE LESS PRORATION - r PLUS PENALTY F OTHER 4 OTHER p� € V S} U ) Dale Receipt No. Permit No. lssuance Date Mailed Delivere Received by - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK70N,CA 95201