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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. - --, FORAoFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL " (COMPLETE IN TRIPLICATE) "WATER QUALITY G Application is hereby made to the San Joaquin Local Health District fora permi t to construct and/or install the work herein described.This application is C1( made in compliance ginuOrnce No.1862 and t�lpaaZgt�ons of the San Joaquin Local Health District. Exact Site Address _fir �.� .�_. City/Town Owner'sName -g(C-414',t',�t7 VIAI Phone Address 6-// /y 75-C4,106 �57-. City Geo/ Contractor's Name w6ZL, -Pei License Phoneme Contractor's Address :P_jQ_63 f 3 Ciiii Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesX No TYPE OF WORK (CHECK): NEW WELL� DEEPEN 11RECONDITION❑ DESTRUCTION❑ I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ 8 r Qf � i DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other 3 Property Line Private Domestic Well 4XV ! 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 �� t Rd 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 l Type of Pump H.P. PUMP REPLACEMENT:; ❑ State Work Done PUMP REPAIR: ❑ State Work Done I DESTRUCTION OF WELL: Well Diameter > Approximate Depth Describe Material and Procedure " 4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 + 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 ofithework forwhich this permit is issued, I shall not employ any person in such manner as to become subject to work man's:`cO'mpensation laws of California." t -Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the perforrmance of the work forwhich this --permit is-issued, I shall employ persons-subject to workman's compensation-laws•of,Califorriia"' I'willocall for a Grout Ins t, pr' r to grouting and a final inspection. Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE i ` Application Accepted By Date Additional Comments: i Phase 11 Grout inspection Phase III finalspection� Inspection By Date Inspection By Date u7 F fee Is due: ❑ ANNUALLY PER UNIT PER SITE C] EACH ❑ January 1 8 Rec ived By January 31 ❑ July 1 8 Received By July 31 j REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT .FEE LESS PRORATION PLUS PENALTY OTHER OTHER 4 Received by Date Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 3Z 1601 E.HAZELTON AVE.,P.O.Box 2009 . STOCKTON,CA 95201 F