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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: • APPLICATION 03615 t„� Q Q (For Non-Transferable, Revocable, Suspendabl ""'"`� -- -- - ENVIRONMENTAL HEALTH PERMIT PUMP &WELL^ '- (COMPLETE IN TRIPLICATE) WATER QUALITY 0`S� 0 Application is hereby madeto the San Joaquin Local Health Districtfora 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 Adores "1474N. on Rd. Chy/Town Z. =zOwner's Name PhoneAddress City Contractor's Name License# 92 5'"S Business Phone'/17�f :UContractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No l TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTION El o� WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IR PUMP REPAIR❑ REPLACEMENT❑ e 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 ��y� /\ ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavationes ) ❑f�l DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing g fl�i ;4 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5 _ El CATHODIC PROTECTION JR ROTARY Type of Grout 01 h 7—o A i 1 e ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: 1ar-- P c To r PUMP INSTALLATION: Contractor -�ow,JK Type of Pump ` H.P. PUMP REPLACEMENT: 11 State Work Done 1 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 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 will call for a Grout Insip on prior to grouting and a final Inspection. Signed X 7 cI,E� Gid_ Title: Date: 4, (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I el_ Date _) " Application Accepted By� Additional Comments: / , Phase II Grout Inspection h as 111 Final Inspection Inspection By Date Inspection By IDate 7 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE g REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER M12 67 ) � Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered - --- APPLICANT—RETURN A!L CQPIEs To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 401 E.HAZELTON AVE.,P,0.aqx 2009 STOCKTON,CA 95201 _._,