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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. APPLICATION R OFFICE USE: (For Non-Transferable,Revocable, Suspendable) PUMP&WELL " ENVIRONMENTAL HEALTH PERMIT WATER QUALITY (y,r,PLETE IN TRIPLICATE) j ication is hereby made to the San Joaquin Local Health District for a permit to construct and/or of San Joaquin Local Heal OistraippllCation is , ApPI N made in compliance with San J�q In County Ordi c;a N�,1862 and t rule d r uta L C _ City/Town t Exact Site Address- Phone Owners Name City 1 Address -- V _ » _ License#%� Business Phone Contractor's Name_ __ Emergency P one �. - ---- Contractor's Address No Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes TYPE OF WORK (CHECK): WE WELL ANDONMENT ❑DEEPEN❑ OTHERRECONDITION ❑ ITL PUMP INSTALLATION AT ONN❑ESTRUCTION❑ PUMP REPAIR❑ WELL CHLORINATION REPLACEMENT❑ Sewer Lines Pit Privy DISTANCE TO NEAREST: Septic Tank — Cesspool/Seepage Pit Other Sewage Disposal Field_. Public Domestic Welt - Property Line Private Domestic Well j INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation- ❑ DRILLED Dia. of Well Casing DOMESTIC/PRIVATE Gauge of Casing""+"""`�-� ❑ DOMESTIC/PUBLIC ❑ DRIVEN ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout N ❑ OTHER _- Other Information y ❑ DISPOSAL — t 11 GEOPHYSICAL Surface Seal Installed By: s PUMP INSTALLATION: Contractor H P. Type of Pump PUMP REPLACEMENT: ❑ State Work Done MP REPAIR: State Work Done Well Diameter Approximate Depth --4-STRUCTION OF WELL: _ --- 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., M 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." ` t t will call for a Gro71pection prior to grouting and a final inspec n. -.a STitle: Signed X - Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Iaa , — Date Y/9/8o Application Accepted By - - Additional Comments: - -- Phase If Grout inspection Phase III Final inspection 11 Inspection 511Z9190— on By _—. Date_-_ _ Inspection By -j- tZ 19— ' a 1i Fee IS Due: El ANNUALLY � ❑ PER UNIT ❑ PER SITE C3 EACH,, El January 1&Received January 31 ❑ July 1 &Rede_l aR�dEBy July 31 BASE, EXPLANATION BILLING r.aREMITTANCE S AMOUNT DUE CHECKED , pL DATE DATE REMITTED AMOUNT FEE 1 — t .s LESS PRORATION PLUS t PENALTY --- OTHER r OTHER Received by Date Receipt No. ermll No. Issuance Date Mailed � rvered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O."12000 STOCKTON,CA 9 %