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Applications Will Be ProcessedWhen Submitted Propel t-omplell oeoure IU •71911 rrra.,rN,•.a.....• - FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) �--- PUMP&WELL ENVIRONMENTAL HEALTH PERMIT 4�e (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 County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address Y s, �Q City/Town Owner's Name Phone ' 7 70— Address 0—Address O City Contractor's Name License#��1 3�� _ Business Phone ~-� 3L Contractor's Address Emergency Phone Is Certificate Of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Ol PUMP REPAIR �r REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines _ Pit Privy p , Sewage Disposal Field Cesspool/Seepage Pit Other 1� 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 19 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ... . ❑ GEOPHYSICAL Surface Seal Istalled By: y PUMP INSTALLATION: Contractor_ � cf'�- "`�� 41 1 Type of Pump H.P. © H 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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-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." I w' all r a Grout pection p' r to grousing and a final inspection. `�'" -�/ i7 d Signed X isle: Dale: (Draw Plot Plan on ReversAide) FOR DEPARTMENT USE ONLY c PHASE I Application Accepted By Date Additional Comments: Phase 11 Grout Inspection Phase Ili Fi alSpeclIon Inspection By Date Inspection By ?ate _ �II,4 Fee Is Due: El ANNUALLY ❑ PER UNIT El PER SITE E] ei EACH ❑ January i &Recve y January 31 ❑ July 1 &Received By July 31 REMIT RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE n pDATE REMITTED AMOUNT FEE ✓ Y L✓ LESS - PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered ON AVE.,P.O.Box 2009 STOCKTON,CA 95201 APPLICANT— ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT •-