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{ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION -- (For Nan-Transfi:abje, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY, Application is hereby made to the San Joaquin Local Health District for ape rmitto construct and/or+instal I the work.here!n described.This application is made incompliance wiVi San Joaquin County Ordinance No.1862 and he .rules and regulations of the-San Joaquin Local Health District. Exact Site Address _ (E�_ _� A-. a..YC� c k City/Town �- Owner's Nam �JL'� t.-(l�tL tib:_:ra a . w Phone " 5 '� a✓ ti 1 O ,_ Address 'Ic 0 ' w .. r c ) City Contractor's NameLicense `7'. 'Business Phgne Contractor's Address Emergency Phone t ' `Ft" Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �'� No .- TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECO'N'DITION C] DESTRUCTION❑ —T - WELL-CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Ot---�PUIMP 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 ❑ IN USTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing II ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 6 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 1 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information } ❑ GEOPHYSICAL - Surface Seal Installed By: PUMP INSTALLATION: Contractor AU F Type of Pump5 H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: - Well Diameter Approximate Depth' Describe Material and Procedure 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." - rl will cal ora rout Inspe on prior to grouting and a final inspection. Signed X __ L e�- Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI41 a Application Accepted By y Date _ Additional Comments: Phase II Grout Inspection . i Phase II anal Inspection ' Inspection By—_ y ( - --Date Inspection By Date ..-Fee Is Due:❑ ANNUALLY ❑'PER UNIT ,. ❑ PER SITE ❑ EACH: ❑ January 1 &Received By3anuary-31 ; ❑ July 1 &Received By July 31 - # - BILLING r REMITTANCE - $ REMIT BASE' EXPLANATION AMOUNT`DUE CHECKED :- DATE DATE REMITTED AMOUNT FEE �� V LESS PRORATION PLUS 2 - PENALTY OTHER OTHER Received,by Date Receipt No. - Permit No.C/{Il Issuan Date; / Mailed Delivered �. s APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95291 .. I