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JDJFOR JFFIGE usE: ,r* APPLICATION �, ++,, #`or Non-Transferable, Revocable, Susp ble)T. 1 ENVIRONMENTAL HEALTH P MIT 1979 PUMP&WELL ` (COMPLETE IN TRIPLICATE) WATER QUALITY cc AA Q� � LQ,rCAL 00 Application is hereby made to the San Joaquin Local FtealthDistrictforapermit toconstructand/orr7�st CA k��i�i�esC�ibed.Thisapplicationis made in compliance with San Joaquin County Ordinance No. 1862 and.fhe ules and regulations o��aInJoaquin Local Health District. Exact Site Address City/Town Owner's Name _ .1 � f Phone Address C City Contractor's Name S "1License#t�.��>t' Business Phone Contractor's Address --c2pa3 Emergency Phone A Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes /J/ No PIZ TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITIONIf WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRL 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 y. © INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 ❑ DOMESTIC/PRIVATE ❑ DRILLED ------Dia. of Well Casing ❑ DOMESTtC/PUBLIC ❑..DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal © CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed 13y:,� PUMP INSTALLATION. Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 19State Work pone 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 issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's-hiring orsub-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 ca r a Grout Inspection prior to grouting and a final inspectiol Signed X Title: _ W Date: _�1 —OZ2 ,9 (Draw Piot Plan on Reverse Side) FO DEPART ENT USE ONLY PHASE I Application Accepted By Date Additional Comments: Phase II Grout Inspection Ph III Fin Inspection r^ 9 Inspection By Date Inspection By44;= Fee IS Due: 1:1 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT DATEDATEREMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuance Date Mailed belivered .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.O:8ox 2009 STOCKTON; p