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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION I (For Non-Transferable, Revocable, Suspendabie) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San Joa In Coun Ordinance NQ. 162 a the rules and regulations of the San aquin Local Health District. Exact Site Address L City/Town P Owner's Name VL' Phone Address �' — �.�4� City 2 t 1._ . �� on - Contractor's Name License Business Phe E•rAf G�L�� Contractor's Address �— Emergency Phone I td Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11RECONDITION❑ DESTRUCTION 11 (rt WELL CHLORINATION 1111 ,� WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION ii_ PUMP REPAIR v�1 REPLACEMENT❑ r 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�STRIAL E] CABLE TOOL Dia. of Well Excavation `DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing k ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ! ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL C Surfaces Seal J nstalled By: _ PUMP INSTALLATION: Contractor Type of Pump H.P. C_ PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner 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." r a Grout Inspe tion prior to grouting and a final inspection. Signed Title: i�u?r mate• •b Draw Plot lot Plan on Reverse Side) I• i FOR DEPARTMENT USE ONLY i PHASE 1 / �- Application Accepted By c� C�� _-1 Date fa ��0 � Additional Comments: Phase II Grout Inspection hese III F' at Inspection Inspection By Date . Inspection By ate I- Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jqquyy 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 REMIT BASE EXPLANATION BILLING REMIT)WE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS 1 PRORATION PLUS PENALTY OTHER OTHER C a_. I f Received 6y pate `Receipf No. Permil No fissuance Date - Mailed ered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICER 1601 E.HAZELTON AVE„P.O.Box 2009 STOGKTON,CA 95201 )