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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) 1 PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ori nstall the work herein described.This application is made in compliance with San J aquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address e�u� C'>L City/Town _l3 Owner's Name _ Phone e,-1-5 Address City Contractor's Name License k Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ` 4 - TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[] �tl �+" Od WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IJP PUMP REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy O Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL �❑ IND TRIAL ❑ CABLE TOOL Dia.of Well Excavation STIC/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 ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL .4 Surfac Seal Installed By: PUMP INSTALLATION: Contractor 71 � - Type of Pump " " p"' 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 performanceof 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 will 11 f a Grout Ins Ion prior to grouting and a final inspection. Signed Title: CnA r'312-� Data. I( (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE 1 ', �o? Application Accepted By Date Additional Comments: Phase 11 Grout Inspection P 8 Final Inspection �y Inspection By Date Inspection By�fJ�•Y------% Date Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE y� LESS PRORATION PLUS PENALTY OTHER \. OTHER �tlal ��- Received by Dete Recei0l No. Permit No. Iso an Date Madetl Del e d APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801E HAZELTON AVE,P.O.Box 10119 STOCKTON,OA 95201