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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE:- APPLICATION I (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is m made in compliance with San Joaquin Dunt Ordinance No. 1862 and the rules and regulations of the Sar��l agyp Lo al Health District. ` Exact Site Address _Z 04 2 � g• �AlVAJ/►'�J City/Town f� (11� of �C Owner's Name fQ N Phone Address VRQLA U Ps!-.A City __Jp/�(efd `Ct Contractor's Name SLA I 6, Xt _() t License#�r.. f -- Bu�s/iness Phone of - Contractor's Address !mak f, t t �* firI t' t Emergency Phone f e,7'~ (7' 1 Is.Certificate of Workman's Compensation Insura n File With SJLHD? Yes t ' No _ TYPE OF WORK (CHECK): NEW WELL 13' DEEPEN ❑ RECONDITION 13 DESTRUCTION WELL CHLORINATION 0 WELL-ABAN©ONMENT OTHER ❑ PUMP INSTALLATION ❑ 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 INTENDED USE � TYPE OF WELL ❑ IPUSTRIAL y '❑ CABLE TOOL Dia. of Well Excavation ee I'DOMESTIC/PRIVATE= ❑ DRILLED Dia. of Well Casing ' E] DOMESTIC/PUBLIC C1 �D .Herr— Gauge of Casing ' ,�,,.� 11 IRRIGATION Lt GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION '❑ ROTARY Type of Grout 117fA), e- ❑ DISPOSAL 1:1 OTHER Other information _ a ❑ GEOPHYSICAL Surface Seal-Installed-Bys PUMP INSTALLATION: `Contractor =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 y 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-contracting signature certifies the following:"1 certify that in the performance of the work for which this k permit is issued I shall e y persons subject to workman's compensation laws of California." I will Grout In p tion prior t grouting and a final inspection. Signed X f ` Title: . +C`i 3 Date: l°t! k1 . (Draw Plot Plan on Reverse Side) ' Y FOR DEPARTMENT USE ONLY PHASE !, Application Accepted By - _ �•� Date Additional Comments: Phase fl Grout Inspection PhaserlH Final Inspection Inspection By f Date. Inspection By - Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 7. July 1 &Received By July 31 REMIT BILLING REMITTANCE l $ _.._AMOUN7_pL4E_ --. CHECKED._ z. .,..,,.,.,,_r;..._. ..�..,.,� ....,..._BASE.____. -__,.-EXPLANATJON.� --:-.e—.�....F �-•- - - ..,. _- __.. ��... .-,.. DATE �'� DATE '�� REMITTED'"- AMOUNT FEE 3 PRORATION PLUS N PENALTY OTHER OTHER `79�- 1 \ t -7 Received by ate Receipt No. - -Permit No. - Issuance Dale Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O-Bos 2009 STOCKTON,CA 95201