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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP WE-L --� ENVIRONMENTAL HEALTH PERMIT !7M � (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 Joa uin Count Ordinance No. 1862 and the rules and re ns4.4-the San Joa u'n I Health District. Exact Site Address�� 3e I ��L ©Oz �m/Town E 71A. ' Owner's Name /�'�r ` - Phone 1 AddressCity 0 `i Contractor's Name v�"� License 7Lf Business Phone Contractor's Address Emergency Phone 36 9' . 1 } Is Certificate of Workman's Compensation Insurance on File With.SJLHD? Yes le— No } TYPE OF WORK (CHECK): NEW WELL&—DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 93— PUMP REPAIR El REPLACEMENT❑ y/ DISTANCE TO NEAREST: Septic Tank l� y Sewer Lines �l� � Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line_ Private Domestic Well Public Domestic Well INTENDED USE „ TYPE OF WELL ❑ INDUSTRIAL 13CABLE TOOL Dia. of Well Excavation �- EJ—DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION 0, �GGR�AAVEL PACK Depth of Grout Seal 119 CATHODIC PROTECTION KOTARY Type of Grout / ) ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal installe By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work pone 7!! PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure... 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." >3 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 c -f`or as Grout Inspection prior to grouting d final inspection. Signed X �"� Title. e Date: Z!74 (Draw Plot Plan on Reverse Side) 4 FOR DEPARTMENT USE ONLY PHASE I r A -Application Accepted B Date , pP P y Additional Comments: Q I out Inspection a AP III Final Inspection } y ✓ 4 inspection By Date Inspection B Date Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 4 &Received By January 31 - ❑ July 1 &Received By July 31 f REMIT „ BILLING REMITTANCE $ AMOUNT DUE CHECKED - Y - - BASE. EXPLANATION - DATE DATE REMITTED { AMOUNT FEE a LESS PRORATION PLUS PENALTYli - OTHER OTHER I ILL Received by ate Receipt No. er it No. Is ante Date Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 RETURN .