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Applications Will Be Processed When Submitleiiperly Completed. Be Sure To Sign The Application. FOR OFFICE USE: , APPLICATION It✓e� 0 (For Non-Transferable, Revocable,Suspendable) ��PumP&W ENVIRONMENTAL HEALTH PERMIT j (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and !or installthework herein described.This application is made in compliance with San Joaquin ounty Ordinance No.1i3 2 and the rules and regulations of the San Joaquin Local Health District. ) Exact Site Address i City/Town r M Owner's Name Phone Address City '��"� 4 Contractor's Name k c.�.� _ License# Business Phone Contractor's AddressEmergency Phone 45 Certificate of Workman's Compensation Insurance on File With SJ HD? Yes >e No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 0. DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ f DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I Sewage Disposal Field Cesspool/Seepage Pit Other t r Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation I�$ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �h ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Cry ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor ti Type of Pump SIC b H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: If State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure i 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. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit i is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California ' i Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensation laws of California." I if call for a Grout Inspect' p 'or g o g and a 'nal inspection. g e: —9. �" Date: /J Si ned X ' (Draw Plot n on Reverse Side) FOR DEPARTMENT USE ONLY ` PHASE 4 �j fl Date Application Accepted By �-�-- 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 - REMIT l BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED 1DATE DATE REMITTED AMOUNT FEE (4 LESS PRORATION PLUS PENALTY OTHER h I OTHER � 11 18 '�0 6 Received by Date Receipt No. Permit No. ssf uance Date Mailed Delivered r STOCKTON,CA 95201 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 .