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Applications Will Be Processed When Submitted Property t.omple�VWFWim;�•sf• a FOR OFFIMTRIPLICATE) APPLICATION ,A 1 (For Non-Transferable, Rev/ocable,Suspen bye) MP&WELL ENVIRONMENTAL H jEALT 4 pERMITr� WATER QUA.i.ITY, �`� (COMP TE IN Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo�rk�h�erein described.This application is made in compliance with San JoaquinCount Ordinance No. 1862 and the rules and regul tivnayo f*tfl4 Ek@�in Local Health District. a r,+�� Glty/Tov- Exact Site Address/b c� �' { I I + %- 19 Phone Owner's Name City Address ° Contractor's Name di License# 6 Business Phone PQM �, 7 Emergency Phone Contractor's Address No Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ r ,� WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 2"" PUMP REPAIR❑ lJ REPLACEMENT❑ Pit Priv DISTANCE TO NEAREST: Septic Tank Sewer Lines y Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED 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 H.P. Ty ate of PUMP PUMP REPLACEMENT: zStateWork Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well 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 to workman's compensation laws of California." is issued, I shall not employ any person in such manner as to become subject Contractor's hiring or sub-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." I will call for a Grout Inspection prior to grouting and a final Inspection. p 'Y (�/t.�-, Date:ALO'S Signed X 11 —.-'� Title: (DrawPlot Plan on Reverse Si ) FOR DEPARTMENT USE ONLY PHASE Ij Date Application Accepted By Additional Comments: Phase II Grout Inspection Phase II al Inspection � Inspection By Date Inspection By to ❑ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 [3 July 1 &Received EMITBy uly 31 Fee IS DUE: ANNUALLY BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT s FEE s ° LESS PRORATION PLUS PENALTY OTHER OTHER / ✓ !`] Received by Date Receipt No. Permit No. I suance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.Hp,ZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9529