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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. APPLICATION FOR OFFICE USE: (For Non-Transferable, Revocable;Suspendabie) PUMP&WELL (/ ENVIRONMENTAL HEALTH PERMIT ` (COMPLETE IN TRIPLICATE) WATER QUALITY : ,, Application is hereby made to the San Joaquin Local Health District fora permittoconstructand/orinstallthework herein described.This application is C�(� made in compliance with San Joaquin County rdinan a No. 1136find the rules and regulations of the San Joaquin Tal Health District. ^� Exact Site Address 19 2 T4� City/Town Owner's Name Phone CA r. City—c5 per_��6..r Address L! Business Phone Contractor's Name r 'I cense#( !/ 7 Contractor's Address " Emergency Phone Is Certificate of Workman's Compensation In urance on Fife With SJLHD? Yes-� No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION 11 WELL ABANDONMENT 13 OTHER El PUMP INSTALLATION ❑ PUMP REPAIR❑ 1 r REPLACEMENT❑ 4 DISTANCE TO NEAREST: Septic Tank o Sewer Lines Pit Privy Sewage Disposal Fielid D D Cesspool/Seepage Pit ' Other Property Line-/—S---+--Private Domestic Well [2 A Public Domestic Well F INTENDED USEWELL r, . TYPE OF W . . is 11 ❑ INDUSTRIAL .��--+-+�-- - rCABLE.TOOa.L_ .. Diof-Well'+�'Exsca%tlon ,DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 11DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 14 i ❑ IRRIGATION ,� GRA_VEL PACK Depth of Grout Seal Type Of Grout a ` . r 13 CATHODIC PROTECTION ......�•�ROTARY,. k ❑ DISPOSAL ❑ OTHER Other Information t ❑ GEOPHYSICAL r Surface Seal installed By: f PUMP INSTALLATION.. 7% Contractor ■ I + k Type of Pump H.P. I P : El State Work Done UMP REPLACEMENT it PUMP REPAIR: Cl State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 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.' Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this l permit is issued, I shalt employ per ris subject to'workman's compensation.Iaws of California." •_ I will call for a out I act' n io iO g outing and a final inspection. Signed X Title: Ar Data: _ + (Draw Plot Plan on Reverse de) _ a i n FOR DEPARTMENT USE ONLY �J PHASE 4 -1-3 i Application Accepted.By_ LLL///vvv��.. - Date 0 i >t Additional Comments: hose II Grout Inspection Phase III Final Inspection qt � A% \ Inspection By Date Inspection By --Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEBA1yI July 31 } BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE CLO �� 4 LESS PRORATION PLUS PENALTY OTHER i OTHER Received by Date Recei'f No. Permit No. •^ is uance ate Mailed Delivered- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E�tTON AVE.,P.O.Box 2009 STOGKTON,CA 9520