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ApplicationsWill 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 for ipe'rmit to coration is istruct and/or install the work herein described.This applicNo. 1$6 a d the made in compliance with San Joaquin County Ordinance p rules and regulations of the San Joaquin Local Health District. ti Exact Site Address 7 of 10, City/Town Owner's Name ' Y Address Phone', City.. Contractor's Name License# 7/ Business Phone Contractor's Address �� ac � Emergency Phone. Is Certificate of Workman's Compensation Insurance on t=ile With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑' RECONDITION❑11 -''=DESTRUCTIONN❑-/ WELL CHLORINATION WELL ABANDONMENT ❑ OTHER D REPLACEMENT❑ PUMP INSTALLATION a�PUMP REPAIR❑ 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 J ❑ INDUSTRIAL ❑ CABLE_TOOL. Dia. of Well Excavation OMESTIC/PRVA ITE i ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ QRIVEN ��" � Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK I Ar Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY �. ., TYRE of Grout r ❑"DISPOSAL ❑ OTHER Other,Information 13 i GEOPHYSICAL t + Surface'Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump [ H.P. PUMP REPLACEMENT: ❑ State Work'D ne ( ' PUMP REPAIR: ` ElState Work Done DESTRUCTION OF_WELL: T9---WeII,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." k 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 c 1 Jor a Grout,inspection prior to grouting and a final inspection. -� Signed1t, , ! Title: _ Hate: 2 (Draw Plot Plan on ReArse Side) FOR DEPARTMENT USE ONLY PHASEI - Application Accepted By / Date / ! Additional Comments: ✓• Phase 11 Grout Inspection Phas II Final inspection Inspection By Date Inspection By Date" Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PERSITE ❑ EACH ❑--January 1 &Received By Januar 31 ? January El 1 S Received 8y July 31 ' BASE EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT 4 FEE t eg 1 LESS 2 PRORATION " PLUS PENALTY �- OTHER ------------ OTHER Rec ed by Date Receipt No.. = Permit No, Issuance Date Mailed Delivered PLIGANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,p.p.go:2008 STOCKTON,,CA 95201