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�- Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign TheApplication. i FOR OFFICE USE: APPLICATION +S �ror Non-Transferable, Revocable, Suspendable) -. PUMP&WELL ENVI•pOIN�M€_NTA_LL E(LTH PERMIT (COMPLETE IN TRIPLICATE) • Ll�P"TEWVupL,TY /�/7�,)Q IT Application is hereby made to the San Joaquin Local Health District for permit to cons11uct�/orI stallthework herein described.This application is made in compliance With San Joaquin County Ordinance No. 1862 and the rules and regulations of the San�{oagquin Local Health District. Exact Site Address !I /7 sg 'r 7/ � r �a h+ i F i C. t� city, __ Owner's NaFng �� ✓r a v izs Phone 3 �`'' s'� '3 ec,'�7 Address T L , ��y�- 1 'e t" City Contractor's Name .,,+�_T ` .'' �� -' License#��1 Business Phone �7 'YJa— Contractor's Address >,xt J-6' Emergency Phone -79/ V7 �J Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes Z. � No TYPE OF WORK (CHECK): NEW WELLO' DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ -PUMP REPAIR❑ UVJ" REPLACEMENT❑ l DISTANCE TO NEAREST: Septic Tank /0 4c, Sewer Lines fst, Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line 3 1!!, Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Die. of Well Excavat' E9 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing VIC ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal s O ❑ CATHODIC PROTECTION 0--ROTARY Type of Grout �`�I` ❑ DtSPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL ^*T Surface Seal sta d By: PUMP INSTALLATION: Contractor ` �'Y Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done 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 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. Signed X -7 Date,Title: �1 Date: 3 (Draw Plot Plan on Reverse Side) FOR EPARTMENT USE ONLY PHASE Application Accepted By J Date Additional Comments: Phase II Or ut Inspection Phase III Final Inspection Inspection By—y� Phase vLG_ inspection By Date „(cam Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 a Received By July 31 BILLING REMITTANCE E REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 4 43 LESS PRORATION PLUS PENALTY OTHER OTHER RA by f paid Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1881 E.HAZELTON AVE.,P.O.Boa 4809 STOCKTON,CA 95101 .qtr.