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ApplicationsWillBeProcessedWhenSubmitted Properly Completed. Be Sure To Sign.The Application. FOR;O UeE USE: ` g APPLICATION (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (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 compliancewithSan Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Addtes5 1 ' go r // .,� City/Town Owner's Name TO *s' de. w�R 41J Phone Address e City Contractor's Name / ua License#_/ Business Phone fr ,6e '� � --� Contractor's Addres$ - r ✓� Emergency Phone Is Certificate of Workman's Compensation Insurance on Fii With SJLHD? Yes No I TYPE OF WORK (CHECK): NEW WELL© DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR IX REPLACEMENT❑ J DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ' Sewage Disposal Field _ .. "Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ 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 Surface Seal Installed By: PUMP INSTALLATION: Contractor ,Type of Pump H.P. c) PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: State Work Done • [mr DESTRUCTION OF WELL: t Well Diameter Approximate Depth .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 J �? ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. fes' Home owner or licensed agent's signature certifies the following."I certify that in the performanceof`thework forwhich this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensatio'114 'of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of tfie_,Work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I ill call for a Grout Inspection r' r to, owing a a final inspection, C9 Signed ` > 9 itle: - Date— (Draw PIW Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Additional Comments: j Phase II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By Date i Fee Is Due: ❑ ANNUALLY PER UNIT C1 PER SITE 13 EACH ❑ January 1 &Received By January 31 El July 1 &Received 8y July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION 4 PLUS PENALTY i OTHER OTHER r Received by Date Receipt No. Permit No, 11suance Dale Maited Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 95201 9