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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION v4.. >"W=or Non-Transferable, Revocable, Suspen,..ole) PUMP&WELL 1/ 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 with San Joaquin County Or inancNa0. 1862 and the rules and regulations of the San aquin Local Health District. Exact Site Address �4>��_,ciC2 c� /9,0 City/Town Ko o!�v Owner's Name e i o Ad Phone Address - City Contractor's Name I ft 0 License Business hone Contractor's AddressEmergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ (� REPLACEMENT❑ r DISTANCE TO NEAREST: Septic Tank Sewer Lines <Q { Pit Privy Ln\ Sewage Disposal Field�/_ d �# Cesspool/Seepage Pit Other Property LineAQ �, Private Domestic Well 10 Public Domestic Well INTENDED USE TYPE OF WELL I ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation T12 DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing a ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing [ lA s c ! U P Vid ❑ IRRIGATION 4 GRAVEL PACK Depth of Grout Seal O ❑ CATHODIC PROTECTION ROTARY Type of Grout I ❑ 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 1 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-contra ting signature certifies the following:"I certify that in the performance of the work for which this \ permit is issue , I shall em to ersons subject to workman's compensation laws of California." I r Gr t Ins c n prior to grouting and a final inspection. / Signed X Title:/�q k',4 Date: / (Draw Plot Plan on Rav rse Side) FOR DEPARTMENT USE ONLY PHASE I � p1/ t _'p-Q^ Application Accepted By Vt7 Date �7 t �b�. Additional Comments: NA as II Grout Inspection ,P as III Final Inspec Inspection By Date �Z��2— Inspection By CgnDate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 3 LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issuande Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 �/