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Applications Will Be Processed When Submitted Properly Completed. Be • Sure To Sign The Application. FOS OFFICE USE; APPLICATION (For Non-Transferable,Revocable, Suspendable) -- ENVIRONMENTAL HEALTH PERMIT PUMP&WELL V (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 w th San Joaquin aunty Ordinance No. 1862 and the rules and regulations of the San J aquin Local Health District. Exact Site Address City/Town j —. Owner's Name Phone Address City Contractor's Name v License Business Phone_ Contractor's Address U Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - No _ S TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 41"'-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 Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _ Q ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout \ ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL IV Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 11 state Work Done t 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. Home owner or licensed agent's signature certifies the following:"I 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." Contractors 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 wit II f a Grout Inspection prior to grouting and a final Inspection. Signed X _ Title: 6/1L& _ Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I — I � , t7 I Application Accepted By 1A7� Date Additional Comments:_ P s ut Inspection �<�$O hase I t pection Inspection ByDate Inspection By __- Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT EJ PER SITE ❑ EACH ❑ January 1 &F1eived By January 31 ❑ July 1&Received Ry July 31 � REMIT RASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED 'ltt DATE DATE REMITTED AMOUNT FEE LESS 4 PRORATION PLUS PENALTY OTHER OTHER o So 2- q, t� Received by Date Receipt No Permit No, Issuance Date Mailed livered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201