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FOR OFFICE USE: 1 y APPLICATION 3 b tt`or Non-Transferable, Revocable,Suspendable) PUMP&WELL 1.. 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 wit an Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, Exact Site Address 5 t� a R%9jrKOa`] City/Town LO- Owner's Name aS�D Phone Address Q O k City L v Contractor's Name L w Ll. License# �� Busin s�Phone V Z.— Contractor's Address 7_0Z Emergency Phone is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION N ❑ WELL AB NDONM'ENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP RqI i 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 d t ,©f INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation I K DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 4 k ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing LIL l r`G p�C I ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I ❑ CATHODIC PROTECTION ROTARY Type of Grout EaTai�I r� ' ❑ DISPOSAL ❑ OTHER Other Information ( ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done p ,, PUMP REPAIR: ❑ State Work Done O/v 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 s Led, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." ",r:s' ' ub-cLnprio ignalureceriities the following:"I certify that in the performance of the work for which this l s subject to workman's compensation laws of California," n p o grouting and a final in9nf—S n4,1 .Signed X Title: 0+ 0 " Dale: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHA5E 1 Application Accepted By `"' O� Date _.. Additional Comments: qhae Grout Inspection r /C7 Phase ill Final Inspection Inspection By Date F ( ( Inspection By J' 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 DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT O I FEE LESS PRORATION PLUS PENALTY OTHER OTHER /- / /W z 1✓ Received by Date Receipt No. Permit No. I suan Date Mailed -Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKYON,CA 95201