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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. .lr� FOR OFFICE USE: APPLICATION '' 1� _ or 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 fora permit to construct and/or install the work herein described.This application is made in compliance w t n Joagnf Count r Ina ce No. 1862 and the rules and regulations of the San J ul cia a Itr B�strict. Exact Site Address !�u City/Town U � mt Owner's NaPhone �v Address me AquiospeL12 ,10 City Contractor's Name fa 45FOU1 A License# Business Phone Contractor's Address%0 2 �� Emergency Phone T� Is Certificate of Workman's Compensation Insura a on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 13 REPLACEMENT❑ ( ©O DISTANCE TO NEAREST: Septic Tank 100 Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other i Property Linea Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 1�3 /� ❑ 11IND TRIAL CABLE TOOL Dia. of Well Excavation__ j MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . 12 �S' L ❑ IRRIGATION ❑ G� L PACK Depth of Grout Seal ❑ CATHODIC PROTECTION tld'ROTARY Type of Grout (�(1 til VAI u ❑ DISPOSAL ❑ OTHER Other Information' ❑ GEOPHYSICAL Surface Seal Installed By_ PUMP INSTALLATION: Contractor 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 issue "I"s II toy p ons subject to workman's compensation laws of California." 1 w' fo p o rior to grouting and a final inspfec on. Signed-X Tiile:t — `"� Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By �`'�-��- Date . Additional Comments: //p/has�l Grout Inspection Phase III Final Inspection Inspection 8y_ ✓L l Date L Inspection By Sti `j? �w:"f bate Fee Is Due: ❑ ANNUALLY Cl PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT r BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED - AMOUNT FEE' LESS PRORATION " PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. ssuance ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201