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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. APPLICATION FOR OFFICE USE: ` J®� (For Non-Transferable, Revocable,Suspendable) PUMP&WELL v ENVIRONMENTAL HEALTH PERMIT J (COMPLETE IN TRIPLICATE) WATER QUALITY 1 Application is hereby made tothe San Joaquin Local Health District fora permitto construct and/or Install the work herein described.This application is made in Compliance with San Joaquin County.Ordinancl No. 1862 and the rules and regulations of the San Joaquinocal th District. Exact Site Address—._ _ ,r 5� — — City/Town JJ/, 4 Phone'. r '• Owner's Name -- City Address Contractor's Name �' License ft 1 I3 InrBusiness Phone 1�A� �_Z— — Contractor's Address � I -—_V — Emergency Phone Is Certificate of Workman's Compensation Insurance on file With LHD) Yes—X No TYPE OF WORK(CHECK): NEW WELL DEEPEN C1 `ECONDITION❑ ' DESTRUCTION❑ .. WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM r REPLACEMENT❑ J. 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 l �� ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC l' - ' ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal — ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER — Other Information -- — ❑ GEOPHYSICAL Surface Seal Installed By: _ PUMP INSTALLATION Contractor �w 7YPe of Pump `Tad H P. -- PUMP REPLACEMENT: ❑ State Work Done --------- PUMP —PUMP REPAIR: IN State Work Done n O DESTRUCTION OF WELL: Well Diameter — Approximate Depth __— Describe Material and Procedure 01 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. l 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 A 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 I will call �for �a�Grout Inspection pill o 1 grchi( and a firtal-Inspection. Signed X �v L Itle: _TI_aj _ Date: g V (Draw Plot Ian on Reverse Side) i FOR DEPARTMENT USE ONLY 4� q PHASE I Date Application Accepted By i Additional Comments:—. — PJAse 111 Final Inspection l Phase II Grout Inspection �f�r/ Inspection By-- �� Date Inspection By ate � I Fee Is Due:❑ ANNUALLY ❑ PER UNIT C3PEn S11 E 11 EACH ❑ January 1 &Received By January 31 ❑ Ju'y 1 &RecelV80 By.July 31 1 I REMIT BILLING REMITTANCE s AMOUNT DUE CHECKED BASE. EXPLANATION DATE 4-• DATE REMITTED AMOUNT FEE Fe.P LESS �..._. -- PRORATION - PLUS PENALTY - — OTHER — OTHER I _ Received by Date - necelpt NO. Penn.t No Is uanre ate mailed Uelrvere0 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA IS201