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ApplicationsWill Be Processed When Submitted Properly CompleteRreToSign The Applic t o� FOR OFFICE USE: APPLICATION f �� wry d f3O2 (For Non-Transferable, Revocable, Suspendable)11 D PUMP&WL ENVIRONMENTAL HEALTH PER Q (COMPLETE.IN TRIPLICATE) WATER QUALITY �QAQI`!!N LOCAL n� HEALTH DISTRICT Application is hereby made to the San Joaquin Local Health DistrictforaPermit toconsfructand/or install theworkherein described. hisapplicationis i 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 ^—� City/Town u Owner's Name a, dC-- jf Phone Address t Citya� Contractor's Name 1. — �G License# /moi S—� Business Phone_a �— M 44/ Contractor's Address `GAGS / �1 Emergency Phone /! rj Is Certificate of Workman's Compensation Insurance on File With SJLHID? Yes L1 No 4 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 4 �[�`� Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well ` INTENDED USE I TYPE OF WELL j ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing X,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 Type of Pump (� i� . H.P. r PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth p1i s 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 performanceof thework forwhich this permit c 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 forwhich this ` permit is issued,11 1 shall employ persons subject to workman's compensation laws of California." I will all for a Grout Inspection prior to grouting and a final inspection. ' r Signed XTitle: .' Date: _ 3 _ (Draw Plot Plan on Reverse Side) — �'------�- - FOR DEPARTMENT USE ONLY PHASE I Application Acceptey- Date �7Z' Additional Comment O l_ Ph a It Grout Inspection ha a III Final Inspection Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar 31 t y July 1 �Received By July 31 BILLING REMITTANCE REMIT BASE EXPLANATION $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY s •.. OTHER OTHER _ f Aeceived 6 ate eceipt No. Permit No. .Issuance Date Mailed Dell11ered APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.O.Hoa 2009 STOCKTON,CA 95201 ;