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Applications W'ilV Be rocessed When u I/ APPLICATION �- PUMP&WELL FOR OFFICE USE, .CQ��,. (For Non-Transferable, Revocable,Suspendable Gi— ENVIRONMENTAL HEALTH PERMIT WAVER QUALITY application is (COMPLETE IN TRIPLICATE) c Health District. adetotheSari'JoaquinLocalHealthDistrictforaperm�U`es and reguiatloOs oftthe San Joaq�all thework ein described.Thls Application is hereby m City/Town made in compliance with San ooaqui County�rdinanc�e'Np. 186 and the O Exact Site Address /c�� Phone 1 011 is �^V City �. Owner's Name Address 'i) Business�Phane License# i Contractor's Name Emergency Phone �� No Contractor's Address �d Is Certificate of Workman's Compensation Insurance on File With JLHD ON 13 INSTALLATION IQ PUMP REPAIR❑ TYPE OF WOR K CHECK): NEW WELL C1 DEEPEN ❑ RECONDITION DESTRUCTION❑ ❑ WELL ABANDONMENT 13 OT f' WELL CHLORINATION Pit Privy REPLACEMENT❑ u Sewer tines Other Septic Tank _Cesspoo4/Seepage Pit DISTANCE TO NEAREST: Public Domestic Well Sewage Disposal Field Private Domestic Well �— � Property Line A ' `" TYPE OF WELL i INTENDED USE I• pia. of Well Excavation [� i ❑ CABLE TOOL C1INDUSTRIAL ❑ DRILLED Dia. of-Well Casing ❑ DOMESTIC/PRIVATE ❑ DRIVEN; Gauge of Casing C3DOMESTIC/PUBLIC (1 ❑ GRAVEL PACK IRDepth of Grout Sea' IRRIGATION Type of Grout k !i ❑ ROTARY Other Information + ❑ CATHODIC PROTECTION :i ❑ OTHER ` 13 DISPOSAL Surface Seal Installed By: I ❑^GEOPHYSICAL I� I Contractor � H.P. PUMP IAISTALLATION: Iia3 Type of Pump ❑ State Work Done PUMP REPLACEMENT: State Work Done approx�togepth PUMP I Well Diameter DESTRUCTION OF WELL: i' Describe Material and Procedure prepared this application and that the work will be done in accordance with San Joaquin County F I hereby certify that I have prep ordinances, state laws, and rules and regulations of the San Joaquin Local Health Derformanceofthe work for which this Per Mit g:,. Home owner or licensed agent's signature certifies the manner 1 certify that int e p aws of California," d I shall not employ any person in such manner as to become subject ify that iinrthe performance oftthe work forwhi h this is issued, Contractor's hiring or sub-contractingon gsubject tore rtwo workman's compensation laws of California." ' permit is issued, 1 shall employ p p or t gr and a final inspeciian. I wi call for a Grout Ins ection p It pale: 74 le: Signed X (Draw Plat an on Reverse Side) FOR DEP RTMENT USE ONLY l� Date PHASE i Application Accepted By Additional Comments: r Phase Ill Final inspection I I Phase II Grout inspection Date r- Inspection By Date Inspection By January 31 ❑ July t &Received By July 31 REMIT Fee Is Due: 13EMITTANCE ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January l &Received y AMOUNT DUE CHECKED BILLING RREMITTED AMOUNT ,I BASE EXPLANATION D E DATE FEE LESS PRORATION �f Z} PLUS! Il PENALTY i G OTHER !' v - i� OTHER � Delivered T issuance Dat Mailed uw79r rnN AVE..P.O.Box 2009STOCKTON,CA 9520 ?