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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION � .� 5D APPLICATION (For Non-Transferable, Revocable, Suspendable) f PUMP&WI=LL F=+'=` ✓� CN� ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY p Application is hereby madetothe San Joaquin Local Health District for a.permi t to construct and/or instal I thework.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 9 /4 d R4 City/Town Owner's Name �"Oe Phone"_. (c� a Address _ City Contractor's Name Licensedt �!f-�� 7 Business Phone_ .Z ; Contractor's Address r Emergency Phone _ � } l.z .7 , Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL S-1 EEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1 li�c f Sewer Lines Pit Privy ° Sewage Disposal Field & Cesspool/Seepage Pit Other i Property Line S_,T Private Domestic Wel! Public Domestic Well INTENDED USE TYPE OF WELL !r ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �® OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 06Z ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal er .1 ❑ CATHODIC PROTECTION P'F!rOTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Install By: PUMP INSTALLATION: Contractor Type of Pump s r H.P:' PUMP REPLACEMENT: ❑ State Work Done' PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure /� f ; L hel reby certify�t at 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:"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 iaws 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 employ persons subject to workman's compensation laws of California." ' 1 will c for a Grout Inspection prior to grouting nd final inspection. Signed X � ��y� - Title: � Date: 47 —P--k 6 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY 7 PHASE I Application Accepted By Date .Additional Comments: 11 Gr nspection � P a inal Ins ction Q y Inspection By Date inspection By Dale f G Fee Is Due: ❑ ANNUALLY © PER NIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ,}uly 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE, DATE REMITTED /p�{ AMOUNT 0 i FEE - 0 I; 'LESS PRORATION PLUS PENALTY OTHER OTHER . - Received by - - Date'" _ Receipt No. Permit No. IS uance Date Mailed Delivered - RN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201