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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) r' PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (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 Joaquin Count Ordinance No. 1862�and the .rules.and regulations of the San Joaquin Local Health District. Exact Site Address37, -,, f✓�A �h+.e �I .~ 1 City/Town Owner's Name Phone" c - ��71 Address 1 ..,,�-...� ",F�r= � 1 art 4,•• w..r .,� rc `?!vb City ry r, Contractor's Name �� t }. License#_K32tn' l� Bu=siness Phone 1 f Y e�c.si jEJ 9=: ' ' .- I Contractor's Address v:Emergency Phone`" tt � Is Certificate of Workman's orrpensation Insurance on File With SJLHD? Yes _ No TYPE OF WORK(CHECK): NEW WELL❑-. DEEPEN ❑ RECONDITION❑ DESTRUCTIONEP--"'PUMP ❑ (y„ 'WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 1:1 PUMP INSTALLATION EP- PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ' Sewage Disposal Field. -Cesspool/Seepage Pit Other Property Line - Private Domestic Well Public Domestic Well 4. ~INTENDED USE TYPE OF WELL ` 11IN �STRIAL ❑ CABLE TOOL Dia. of Wel]:Excavation G DOMESTIC/PRIVATE, ❑ DRILLED Dia. of Well Casing f. ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout f ❑ DISPOSAL 0 OTHER Other Information © GEOPHYSICAL Surface Seal Installed By: I�1 PUMP INSTALLATION: Contract V ' Y Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑,State Work Done ' DESTRUCTION OF WELL: 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 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 became 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, I shall employ persons subject to workman's compensation laws of California." �ra Grout In ection prior to grouting and a final inspection. - Title: _ Date: } (Draw Plot Plan on Reverse Side) _ FOR DEPARTMENT USE ONLY ' � PHASE I Application Accepted'By Datef� Additional Comments: Phase 11 Grout Inspection i 3 Ph e I =nal Inspection ...Inspection By Date - -- Inspection By id A Date 2-�34-/ I- Fee IS Due: ❑ ANNUALLY ❑LPER UNIT . ' ❑ PER SITE_ ❑ EACH"` "❑ January 1 &Received By January 31 ❑ July i &Received By July 31 BILLING— .- REMITTANCE t .$ REMIT 1 BASE EXPLANATION - AMOUNT DUE CHECKED _ _ F DATE + :; DATE REMITTED AMOUNT FEE' PRORATION - PENS g PENALTY t OTHER OTHER. YReceived by -Date — Receipt No.' -- Permit No-- - �-v r .- issLranibe Date Mailed' . ' Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 -