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Application`s Will Be Processed When Subm4hed P�,nperly Completed. Be Sure To Sign The Application. FOR)IlICE USE; ' APPLICATION I I # (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN RIPLICATE) WATER QUALITY Appl ication is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance w! a dqul un rdinance No. 1862 the rules and regulations of the Sa poaquin Local Health D' t ric . I Exact Site Address I� City/.TownZZ �� Owner's Na J �tvl �E Phone Address ` City Contractor's Name " nse#� �� Business Phone Contractor's Address L� 9:7 Emergency Phone I-- r Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �"� No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ` WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATI0%e PUMP REPAIR REPLACEMENT❑ j`" l _ DISTANCE TO NEAREST: S40 Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property LinW. Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL_ Dia. of Well Excavation t ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ' ❑ DOMESTIC/PUBLIC i ❑ DRIVEN Gauge of Casing k ❑ IRRIGATION I ❑ GRAVEL PACK Depth of Grout Seal 60 r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout O ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: l_ PUMP INSTALLATION: I Contractor i Type of Pump I A21i.P. PUMP REPLACEMENT: i ' 2—State Work Done PUMP REPAIR: I ❑ State Work Done DESTRUCTION OF WELL: Well Diameter pproxlmate ept [ave Describe Materia and Proc Jure I hereby certify that I 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 ei ioy any person in such manner as to become subje t to workman's compensation laws of California." Contractor' g r sub-con signs#ere certifies the following." er fy that in the performance of the work for which this per is i d, s all employ rson subject to workman's comp nsa i n laws of California." I Ill t Ins ect' rior t routing and a final inspec i Signed X lj Title: Dale: (Draw Plot Plan,n verse Side)— FOR ide)FOR DEPARTMENT USE ONLY PHASEI Application Accepted By I 1 1, Date !S�k—_49,40n Additional Comments: Phase 11 Grout InspectionFlulaI Inspectio' 4' 13/ 1 Inspection By—11; Date Inspection By P_ Date [9 l3 � J Fee Is Due: ❑ ANNUALLY ,y�' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 I BILLING REMITTANCE REMIT BASI'IIf EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED gi. AMOUNT FEE r LESS �f PRORATION P f PLUS 'll PENALTY i OTHER 'll illllli OTHER41 1 ' Received by Date Receipt No. Permit No. seance Date Mailed Delivered .P. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 I , ill - r r