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OFFICE USE: Applications Will Be Processed When Submitted Properly Completed. Be SureToSignThe Application. FOR OAPPLICATION a r (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT" WATER QUALITY �. (COMPLETE IN TRIPLICATE)" - e Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the ork herein described.This application is made in compliance with San J ui Couo1*.Ordina ceN. 1862 and the rules and regulations of the San Joa uin Loca ealt District. Y r /.- ti�� City/Town + Exact Site Address I- � , Owner's Name Fre p /14raM " rd/ Phone Address t4,r� W!Q City !PN� M"d weri. z Contractor's Name 2 a Contractor's Address Emergency Phone1� v + Is Certificate of Workman's Compensation Insurance on File tth SJLHD? Yes No TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 4 REPLACEMENT❑ / t/ DISTANCE TO NEAREST: Septic Tank �� Sewer Lines 7.7 Pit Privy Sewage Disposal Field ' Cesspool/Seepage Pit Other \ Property Linewuj_szt�Private Domestic Well Public.Domestic Well Vl t INTENDED USE TYPE OF WELL O •� ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation ' DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ` ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing k ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information 11 GEOPHYSICAL Surface Seal installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done \4' PUMP REPAIR: ❑ State Work Done Approximate Depth DESTRUCTION OF WELL: Well Diameter 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 i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I 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." i Contractor's hiring a'sub contracting signature certifies the following:"I certify that in the performance of the work forwhich this I permit is 'ssued, I shall a ploy persons subject to workman's compensation laws of California." I w' I for Grout ectio riot togroutin%and a final inspection. - 7 Signed X Title: �F(//(Jr Y' Date: &2— �• (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY 1 PHASE I Date Application Accepted By ° Additional Comments: Phase 11 Grout Inspection Ph a III Final Inspection Inspection By Date Inspection By Date t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT BILLING l' BILLING REMITTANCE $ �,.. AMOUNT DUE CHECKED _ ,BASE EXPLANATION., .DATE DATE REMITTED' AMOUNT FEE LESS• PRORATION i PLUS PENALTY I OTHER OTHER rr�� ! suanc pat Mailed Delivered>f I Received by Date Receipt No. 'Permit o. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 962 r