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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign Tfhe��Application. / FOR OFFICE USE: APPLICATION .— y (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 fora permit to construct and/or install the work herein described.This application is made in compliance witb San Joaquin County 0 divan a No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address Z&qvo City/Town Owner's Name I-D, Phone �� 4 Address � � City Contractor's Name License#� ?ff Business Phone 3 —Iaa Contractor's Address ��f,., �.T Emergency Phone t� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONI�F 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 ❑ II USTRIAL ❑ CABLE TOOL pia, of Well Excavation V DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: 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 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 forwhich this permit is issued. I shall employ persons subject to workman's compensation laws of California." I will c4WIft a Groin I,,,,pection prior to grouting and a final inspection. SigneTitle: —17 — _. Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Aw Date Additional Comments: Phase 11 Grout Inspection �jP��h eJ,�I mal Inspection�O _/j V Inspection By Date Inspection By !�✓ Date !G' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE s LESS PRORATION PLUS PENALTY OTHER r OTHER F Received by Date Receipt No. Penmit No. Issufince Datlli I Mailed Delivered . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 f