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Apjjtl I ns Will Be Processed W e A�plffll n,fW!llft�PLICATION ted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: �JUN� 2 1 JPQ? tl Won-Transferable, Revocable, Suspendable) PUMP&WELL ' SAN JOAQUIN EL"APNMENTAL HEALTH PERMIT !_ (COMPLETE IN TRIPLICATE) HEALTH DISTRICT WATER QUALITY Application i;hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This appligation is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regula 'ons of the Sa J aquin Local Health Distr ct. Exact Site Address t _9 City/Town �GC- J Owner's Name I&A-SA-3 / f Phone AddressCity� t7o`G1� 3� / Contractor's Name r License# 90�/ Business Phone 15y11-1T_&KI Contractor's Address r 5, _ ergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Y No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 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 ❑ INDUSTRIAL ❑ 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 ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 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. 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:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout In ection prior to grouting an a final inspection. S� Signed X " I Date: Ll 7t� (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE 1 Application Accepted By Date Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE mo LESS PRORATION PLUS PENALTY J OTHER CGU rJrh l k C OTHER /141-4,610( L Received by Dae Receipt No. Permit No. I uance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201"-------