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l Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION ,, .. (For Non-Translerable, Revocable, Suspendable) PUMP&WEL r 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 with a Joaquin County Ordinance N . 1862 and the rules and regulations of the San J quit Local Health District. Exact Site Address City/Town Owner's Name Phone - '71 Address City_ r Contractor's Name ft ` icense#: � _ Business Phone ' Tf7�'S ell 1.17S t C Contractor's Address Emergency Phone 79� f,;,� - Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A__� No �- ' TYPE OF WORK (CHECK): NEW WELLM'DEEPEN ❑ RECONDITION 11DESTRUCTIO�N/❑ t WELL CHLORINATION C3 WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank _. Sewer Lines Pit Privy F Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ,�x� ❑,�, INDUSTRIAL �❑ CABLE TOOL Dia. of Well Excavation L�DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing `r ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casings , Ry6 ❑ IRRIGATION ❑ GFVEL PACK Depth of Grout Seal r ❑ CATHODIC PROTECTION ®—ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information 11 GEOPHYSICAL Surface Seal Installed By: /`F/I'1 de-o-2, ' PUMP INSTALLATION: Contractor _ .. C .Type of Pump H.P. f� PUMP REPLACEMENT: ❑ State Work Done__... Lt0 PUMP REPAIR: to Work Done DESTRUCTION OF WELL: Well Diameter rvximate Depth r- Describe Material and Procedure ( t 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 fotlowing:1 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 - I w ill call 1 r a Grooult Ins ection prior to grouting and a final inspection. / Signed X 3 /� ! �re.? Title: �,,� Date: /bx/rf� (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By L , ' _ Date Additional Comments: Ph a It Grout Inspection / Phase III Final Inspection ,Inspection By D#te�41 Inspection B Date Fee Is Due: ❑ ANNUALLY E] PER UNIT PER SITE ❑ EACH 13 January 1 &Received 6y January 3 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER { P? 5< s- k 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.O.Box 2009 STOCKTON,CA 95201 Y