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FOR OFFICE USE:- APPLICATION (For Non-Transferable;Revocable,Suspendabfe� ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALlTY- AppfJcation is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work.he ein described,This application is made in compliance.,vi ith San Joa in ounty Ord' ce No. 1862 and the les Jind regulation Exact Site Address "''_ ' _ y �ur Lac ealth Distri t. I" I ylTown Owner's Name Address Phone Contractor's Name ;. City Contractor's Address License# " Business Pho e Emergency Phone Is Certificate of Workman's Compensation urance on File With SJLHD? Yes_._ _ No TYPE OF WORK {CHECK): NEW WELL, DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f WELL CHLORINATION 1:1WELL ABANDONMENT 11 . OTHER ❑ PUMP I REPLACEMENT❑ NSTALLATION 0 pU POP DISTANCE TO NEAREST: Septic Tank )6) Sewer Lines — Pit Privy Sewage Disposal Fi Id—�3L /_ Cesspool/See a e P' Property Line Private Domestic Well p g It Other INTENDED USE �Pubfic Domestic Well C ❑ INDUSTRIAL TYPE OF WELL ❑ CABLE TOOLp Dia, of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing *� P © DOMESTIC/PUBLIC ❑ DRIVEN IRRIGATION Gauge of Casing GRAVEL PACK Depth of Grout Seal ~ ❑ CATHODIC PROTECTION ❑ DISPOSALROTARY . Type of Grout ❑ GEOPHYSICAL ❑ OTHER Other Information _ 1 PUMP INSTALLATION:. Surface Seal Installed By: C Contractor Type of Pump "H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL., Well Diameter Describe Material and procedure Approximate Depth d I hereby certify that I have prepared this application and that the work will be done in accordance with San Joa f ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. gt� un d_ Horne owner or licensed agent's slgnalure certifies the following:'•1 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 for which this permit is issued, I shall employ persons subject to workman's Compensation laws of California." I WIIIIII6all for a Grout ection rior to grout and a final Inspection. Signed X IiP e' Date: (Draw Plo n on Reverse Side) PHASEFO EPARTMENT USE ONLY Application Accepted By Additional Comments: Oat 6 Phase 11 Grout Inspection P a I11 Final 1 Inspection B _ p � �S � pection By Date ^-� Inspection"B Dat Fee Is.Cue: ❑ ANNUALLY ❑ PER bN1T ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 Cl July 1 8 Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE REMITTED AMOUNTO E CHECKED FE=E / AMOUNT LESS PRORATION PLUS - PENALTY OTHER OTHER Received by L ate ... Receipt No: Permit No APPLICANT=RE7UAIV ALL coPIi=S TO. -ENVIRONMENTAL HEALTH PERMIT/SERVICES Maded DelivergQ !s uance ate ' - - ;1601;E.HA2ELTON AVE- P. 2009: :STOCk'�ON,CA 85201