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4t Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION ' (For Non-Transferable, Revocable, Suspendable) - —D• ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is f made in compliance with San Joaq in Cou y Ordinance o. 1862 and th rules and g lations of the San J a uin Local Health District. W Exact Site Address City/Town _U Owner's Na e Phone .3 I Address4 , City j Contractor's Name License (+�7L�Business Phone Contractor's AddresstuA Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ pq 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 J Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL i 1 iN t �j' ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ` ❑ DOMESTIC/PRIVATEP �1 ` DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ,42 IRRIGATION GRAVEL PACK Depth of Grout Seal P ❑ CATHODIC PROTECTION ROTARY T t ype of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL I Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑t State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth OVA Describe Material and Procedure 4 h I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f 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 thework 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 orsub-contracting signature certifies the following:"I 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." II will call for a Grout Inspection prior to grouting and a final inspection. Signed X C1 rf e ry Title: (7um (- Dates- (Draw Plot Plan on Reverse Side) OR DE ARTMENT USE ONLY PHASE I, 1 14 Date Application Accepted By Additional Comments: i Phase II Grout Inspection Phase III f incl Inspection Inspection By r Date Inspection By ate C Z -79 Fee Is Due: El ANNUALLY ❑ PER UNIT 13 PER SITE 11 EACH El January 1 &Received By Janu y 31 July 1 &Received 31 'i BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE D T� t DATE DATE REMITTED UN7 FEE V 00 /,�+ �,�/} �r LESS PRORATION „ . ~� AF V`sJ 7/ /�� - PLUS W EL L, PENALTY OTHER OTHER G Received by Date - Receipt No, Permit No. Issuance ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C 0 - ,.