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—p—Q-3 will tse Processed When Submitted Properly Completed:Be Sura To Sigri The Application. y FO'fr OFFICE USE: � APPLICATION {For Non-Transferable, Revocable,Sus y pendable} ENVIRONMENTAL HEALTH PERMIT PUMP&WELL ^OMPLETE IN TRIPLICATE) , WATER QUALITY plication is hereby made to the San Joaquin Local Health District for a permiitto construct and/or install the work herein described.This application is I made in oom¢tiance with San Joaquin County Ordinance o. f 2 and th rules and f Exact Site Atldress A n7�- ! f — §g regulations of the San Joaquin Local Health District. � ♦ 7'/7T Pf�� . City./Town E Owner's Name Address � Phone _ Contractor's Name City 2Q License 4 �� Business Phone` rS Contractor's Address mergency Phone Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL( DEEPEN ❑ RECONDITION DDESDESTRUCTION WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ r � i REPLACEMENT0, II � - DISTANCE TO NEAREST: Septic Tank ! r Sewer Lines Pit Privy yj Sewage Disposal Field_ Cesspool/Seepage Pit Other INTENDED USE Property Line Private Domestic Well_ Public Domestic Wall j� 11 INDUSTRIAL II TYPE OF WELL �f 19 J ❑ CABLE TOOL Dia. of Well Excavation`�� DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN 11IRRIGATION 13�f Gauge of Casing �s GRAVEL PACK Depth of Grout Seal r ❑ CATHODIC PROTECTION ROTARY ❑ DISPOSALOTHER i Type of Grout ❑ � y C3GEOPHYSICAL — Other II Information PUMP INSTALLATION: Contractor t Surface Seal Installed By: � Type of Pump H P � PUMP REPLACEMENT: I ❑ State Work Done PUMP REPAIR; ❑ State Work Done TRUCTION OF WELL: I Weil Diameter Describe Material and Procedure Approximate Depth Q ji I hereby certify that t 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 taws of California." Contractor's hiring or sub-ccontracting:signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall e ploy persons subject to workman's compensation laws of California." t I wi ycall for a Grout Inspe11 n prior to groutin and a final inspection. Signed X _ Title: Date: I (Draw t Plan on Reverse Side) 11 FOR DEPARTMENT USE ONLY PHASE? //l ,��' 1 Application Accepted By 11 " a,& © Date Additional Comments: - P e I rout Inspection y/ Phase Ill Final Inspection Inspection B >e Date_r `Y Inspection By Cja4-W. Date Fee is Due: 13 ANNUALLY i'EF UNIT PER SITE 13 EACH u ❑ January t&Recewetl fly January 37 ❑ July 1 8 Received By Juiy 37 BASE U EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE I REMITTED AMOUNT DUE CHECKED FEE j -- AMOUNT LESS PRORATION PLUS PENALTY — t OTHER ' OTHER _t 1 Received by+-- Date Reeelpt No. Perms,No. }i I APPLICANT—ReTURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMITISERVICES I`.+yUdrrCe Date Mailed Delivered _ l _,... 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 "