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I Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Fg�E USE: APPLICATION Ir (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) �/ WATER QUALITY 0 L('�_Z2,0.-(p 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 POPI mpliance with an Joa uin County Ordinance No. 1862 and the rules qnd regul t"onbpf he San Joaqui ocal He h� tistrict. Exact Site Addres 5 Owner's Name /1/ 10144-61e, Phone Address E Z_"C_ City Contractor's Name < License 4V065* Business Phone. Contractor's Address 719pe Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 11::::� No TYPE OF WORK (CHECK): NEW WELD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ \ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy VJ Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TY OF WELL ❑ INDUSTRIAL CABLE TOO Dia. of Well Excavation i ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing / gIsAES� /PUBLIC ❑ DRIVEN Gauge of CasingiG 10 ❑ GRAVEL PACK Depth ofGrout SealTHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface}Seal Installed By: PUMP INSTALLATION: Contractor r Type of Pump r/ F �' H.P. bi PUMP REPLACEMENT: ❑ State Work Done O�L_ S 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. 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." Contractor's hiring or sub-co cting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issu , I shall a pl y ersons subject to workman's compensation laws of California." I will for a r t In pe ion prior to grouting and a final inspec Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted B Dat �i l Additional Comments: I de, Phase II gout inspectionhas I final inspection Inspection By Date Inspection y Date b� Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 F BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE i LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 - I