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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. "1FFICE USE: I �ff APPLICATION / (For Non-Transferable, Revocable, Suspendat.,�, PUMP&WELL T 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 Eade in compliance with San Joaquin County Or8 No, 1862 and the rules and re�atitlons of the San Joaquin Local Health District. act Site Address Q X, �s� Sdscr,[ D// �►i 6� o h sf,Af,If4/01 City/Town Owner's Namefy K` a AO Phone Address City ' 0 Contractor's Name License#ZTa '?Business Phone C446L 7 Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No O TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® 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 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout f ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL �^ Surface �S �I Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. V_D 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 rio o out and a final inspection. Signed X lot Ian itie: !.-� Date: (Draw Pon Reverse Side) ` FORD PART NT USE ONLY PHASE Application Accepted By �""" Date Additional Comments: Phase II Grout Inspection Phapejlinal Inspection / Inspection By Date Inspection By r Date L Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKE DATE DATE REMITTED AMOUN FEE LESS PRORATION PLUS PENALTY OTHER OTHER a (PI1� I �, I� � Bc> Received by Date Receipt No. Permit No Iss ance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON,CA 95201