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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. TdR oFVICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT ` PUMP&WELL r (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madetothe San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is i made in compliance with San Joaquin Count 'OrdiVfnce No. 1862/ anaTe rules and rgAlations of the San Joaquin Local Health District. Exact Site Address G�? �J 1..[ d� 1 fs City/Town Owner's Name 21�, moi , Phone a Address _ City Contractor's Name .- License# Business{hone Contractor's Address . Emergency e J Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes P, No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRk 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 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation Lei DOMESTIC/PRIVATE ❑ DRILLED pia. 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 Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. € PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: State Work Done DESTRUCTION OF WELL: Well Diameter Approxim�l Depth Describe Material and Procedure i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County k 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 forwhich this n permit is issued, I shall employ persons subject to workman's compensation laws of California." I wilLcall for a Grout Insp ction prior to grouting and a final inspe � Signed X r Title: Dale/'� (Draw Plot Plan on fleverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted ByDate LCL Additional Comments: Phase 11 Grout Inspection firase III F 61 Inspection Inspection ByDate Inspection By Date—2- Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 R Received By July 31 REMIT BILLING REWTTANCE $ BASE EXPLANAT}ON AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER «. f Received by Date Receipt No. - Permit No. f Issuan a Date Maiied Delivered -_.APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 15DI E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 ., .