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Applications Will Be Processed When Submitted Prioperly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATIONti ( I(For Non-Transferable,Revocable,Suspendablc' PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permiftoconstruct and/or install the work herein described.This application is made in compliance with San Joaq in C,, t,Ordinance No. 1862 and th rules and g lotions of the San J a uin Local Health,District. (� Exact Site Address City/Town y Owner's Name Phone Address City i Contractor's Name LicenseBusiness Phone ` Contractor's Address -.Emergency Phone Is Certificate of Workman's Compensation Insurance on File-With SJLHD? Yes No TYPE OF WORK (CHECK): NEIN-WELLq=7 DEEPEN ❑ RECONDITION© DESTRUCTION❑ 1� WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ Illy REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy t Sewage Disposal Field Cesspool/Seepage Pit Othe,_0_ }j Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL , rI i 13 INDUSTRIAL INDUSTRIAL ❑ CABLE TOOL Dia. of WExcavation ) ❑ DOMESTIC/PRIVATE � DRILLED Dia. of Well Casing f' ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - C " '2-IRRIGAT OND J4 GRAVEL PACK Depth of Grout Seal 11 CATHODIC PROTECTION JP.ROTARY Type of Grout ❑ 'DISPOSAL ❑ OTHER Other Information ~~ ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. t. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure h 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 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 I will call for a Grout Inspection prior to grouting and a final inspection. [J� Signed X Title: 7'Y1�l�s (Draw Plot Plan on Reverse Side) OR D€ ARTMENT USE ONLY PHASE I // V /` .7 y Application Accepted By Date Additional Comments: Phase It Grout Inspection Phase 111 Final Inspection Inspection By Date Inspection Byq,.(C 1-7 a Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PE SITE ❑ EACH ❑ January 1 8 Received By Janu y 31 July 1 &Received 31 BILLING REMITTANCE $ - BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE D UNIT FEELESS PRORATION �_ /t ✓ ( v PLUS LL, PENALTY OTHER I OTHER G _ IL II f Received by Date Receipt No. Permil No. Issuance ate Mailed Delivered IIF APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C