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Applications Will Be Processed When Submitted Properly completea. me bure to mqri IFlu MPPIIcCILIUFI. FOR OFFICE USE: APPLICATION —it Non-Transferable, Revocable, Suspendable) PUMP &WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework herein described.This application is made in compliance with San Joaquin County Ordina ce No. 1862 and the rules and regulation f the San Joaquin Local Health District. Exact Site Address y �� d�� I / �'E' �- Cit /Town Owner's Name M .Q In 1 � [T Q is��.�� Phone - Address �.D�^- *41r- v City Contractor's Name �� e�1 !a Q,na1% -F 5®N's License#iwj.�},;_(�_ Business Phone -2 VJ- ( a V 7 _ Contractor's AddrdSSL�i�� S !�aw �JI1 Gd fl`Emergency Phone 5. drn-�. Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELLS' DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ �1 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9-' PUMP REPAIR❑ Q REPLACEM ENT❑ DISTANCE TO NEAREST: Septic Tank lib Sewer Lines "66o Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL G3'(ABLE TOOL Dia.of Well Excavation - ❑ ESTIC/PRIVATE 1-1DRILLED Dia. of Well Casing y - ; ESTIC/PUBLIC ❑ DRIVEN Gauge of Casing %-KRIGATION ❑ GRAVEL PACK Depth of Grout Seal - - ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - ❑ DISPOSAL ❑ OTHER Other Information - - ❑ GEOPHYSICAL Surface Seal Installed By: --- J PUMP INSTALLATION: Contractor Type of Pump :n, to i H.P. PUMP REPLACEMENT: ❑ State Work Done - - 0 PUMP REPAIR: ❑ State Work Done — - lT DESTRUCTION OF WELL: Well Diameter Approximate Depth -- Describe Material and Procedure - r 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. slo Signed X a J \ ^ tTn 1 Title: DaleA. _)s�i (Draw Plot Plan on Reverse Side) FOR EPARTM IT USE ONLY PHASE O Application Accepted By Date Additional Comments: Phase II Grout Inspection ,r/ P t foal Ins a e G G Inspection By Date—!/(/ Inspection By d Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ER SITE ❑ EACH ❑ January t a Received By January 31 ❑ July 1 6 Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS ? 3a O PENALTY OTHER OTHER to 80 Received by Dat Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95201