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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application 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 with San Joaquin County Ordinalp,44.1Z and the rules and regulations of the San Joaquin Local Health District. Exact Site Address–141C City/Town t1a. n a - ass Owner's Name ^J Phone .4 q V Address . ' lxa { City Contractor's N'lame c l�.� -» .r >#1 License# Business Phone Contractor's ,td > (�,, -Ta. 1- .r, i Emergency Phone 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 INSTALLATION a' PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer;Llr,es Aj,�, Pit Privy ' Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL - -, ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 111z_ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i ❑ IRRIGATION ❑ GRAVEL PACK, Depth of Grout Seal d ElCATHODIC PROTECTION ':' COTARY Type-of Grout:-{ -❑ DISPOSAL 't ❑'OTHER :_ —Other'Info`rmation—'may ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor , ' Type of Pump +3a H.P. 1. PUMP REPLACEMENT: t1 ❑ State Work Done PUMP REPAIR: ❑ State Work Done 'F DESTRUCTION OF WELL: Well Diameter " Approximate Depth Describe Material and Procedure , I hereby certify thaf l 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 ovork forwhich 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 for which this permit is•issued, I shall employ p&sons.subject to workman's compensation laws of California." I,will calltor.a Grout Inspectic 'prior to grouting anii-a final inspection. Signed _ ~ ., -S Title Date–h.. t (Draw Plot Plan on rs I e ` �. FOR DEPARTMENT USE ONLY PHASE I' _ ... Application Accepted-Sy '` Date Additional Comment's: Phase II Grout Inspection Phase_ III Final Inspection Inspection By Date Inspection By Date .. Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 `` tip_. ....._ REMIT "a +BASE. - EXPLANATION.- BILLING REMITTANCE $ AMOUNT DUE CHECKED ' k LATE--- -DATE. REMITTED AMOUNT FEE o-o 00 15 6 LESS s PRORATION PLUS PENALTY Ir OTHER OTHER Received by Date.1 Receipt No. Permit No j Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ,w