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�-" Applications'Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION 'i (For Non-Transferable, Revocable, Suspendable) PUMP&WELL l ENVIRONMENTAL HEALTH PERMIT i. , i (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 Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address W D S3 S .e� A0, u e w City/Town 14'—'43 o h ,I Owner's Name i^P^I, Phone -3 2 — a 9 Address 4 City s �c�•� Contractor's Name !i_ }- License# Business Phone ') Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN © RECONDITION❑ DESTRUCTION❑ a WELL CHLORINATION ❑ WELL ABANDONMENT E] OTHER 1:1 PUMP INSTALLATION � PUMP REPAIR❑ REPLACEMENT❑ 4 I DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy II Sewage Disposal Field Cesspool/Seepage Pit Other— Property ther Property Line Private Domestic Wel! Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL H ❑ CABLE TOOL Dia. of Well Excavation 12 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 urface Seal Installed By: PUMP INSTALLATION: Contractor I Type of Pump C c n erri� c H P T a7 PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 1 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:N 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." i Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this i permit is issued, I shall employ persons subject to workman's compensation laws of California." � [ I will call for a Grout In Spec on prior to grouting and a final inspection. Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY II PHASE I Application Accepted By ry``""` �� Date �y i; Additional Comments: Phase II Grout Inspection Phase Ili Final Inspection Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY "❑ PER UNIT IN PER SITE ❑ EACH Cl January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE " EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED _ - DATE DATE REMITTED AMOUNT - FEE LESS PRORATION PLUS {i PENALTY i OTHER n OTHER . r o � s �- Received by Date' Receipt No Permit No, Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.Q.Boz 2009 STOCKTON;CA 95201 S ,