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€ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, F-OR^OF ICE USE: APPLICATION - (For Non-Transferable, Revocable, Suspendable) i PUMP&WELL f ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a 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 u es and regulations of the San Joaquin ocal He Ith District. s S'. Exact Site Address /q 4 S City/Town t Owner's Name Phone�4;021 Address J4 City Contractor's Name r►. �o 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 14 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 REPLACEMENT❑ I f DISTANCE TO NEAREST: Septic Tank !�:© + Sewer Lines f? Pit Privy Sewage Disposal Field L-4— Cesspool/Seepage Pit Other Property Line Private Domestic Well '150- f+ Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation k ❑ 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 I ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By. PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done p' PUMP REPAIR: ❑ State Work Done S DESTRUCTION OF WELL: Well Diameter Approximate Depth I 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 F 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 forwhich this permit 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 for which this permit is issued, I shall employp sons subject to workman's compensation laws of California." I w all for a u spe prior to grouting and a final inspection. Signed X Title: Z Date:! (Draw Plot Plan on Reverse(iide) AC P!2 FOR DEPARTMENT USE ONLY PHASE ;7� 7 Application Accepted By Q Date� y Additional Comments: Phase II Grout Inspection ha Ill Final Inspection 1 Inspection By Date Inspection B Date I Fee Is Due: ❑ ANNUALLY Q PER UNIT 1WPER SITE ❑ EACH ❑ January 1 &Receivetl By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT I BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEEde— LESS PRORATION PLUS PENALTY OTHER OTHER '7�t - 1359 !Z 75 Received Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201