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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (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 Or inance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address[[, ��f� 1� ��,. ►�J City/Town Owner's Name Jy� _ 1�-�u11 _. Phone3� 7 Address �/ / ;2 Contractor's Name O License#/4-:)L 3 7 Business Phone 3 r___ X` Contractor's Address 1 3 D 2) ��rEmergency Phone �� G^�! � �,/✓ �.�� 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 ❑ PUMP REPAIR 01 M REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �1 Sewage Disposal Field Cesspool/Seepage Pit Other -� Property Line Private Domestic Well Public Domestic Well ! INTENDED USE • TYPE OF WELL 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 0 OMESTIC/PRIVATE 11DRILLED 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: QState Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth _n ( , n Describe Material and Procedure r . 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 ^`Zj. 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." 1call or a Grout Ippection prior to grouting and a final inspecii n. Signed Xle: Date: , (Draw Plot Plan on Reverse Si e) FOR DEPARTMENT USE ONLY PHASE t166 Application Accepted By Date Additional Comments: Phase 11 Grout Inspection h II Final Inspection` � h �Inspection By Date Inspection B Date `tJ Fee Is Dile: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED // (( AMOUNT FEE s M qS LESS PRORATION PLUS PENALTY. OTHER OTHER �(� a Y Received by Date Receipt No Permit No Iss ante Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201