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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign.Tne APPLICATION FOR OFFICE USE: (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) I WATER QUALITY Application is hereby made to the 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 Ordinance No. 1862 and the rules and regulations of the Sa Joayquin Local Health District. Exact Site Address /J City/Town Owner's Name ��1Z� �O A Z � � C �; Phone lig 7Z- City ' Address ©9 - 1 Contractor's Name !f e. License#�� Business Phoni T-' Contractor's Address r it.Emergency Phone I Is Certificate of Workman's Compensation Insuranocon File With SJLHD? Yes 4LNo TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN 11RECONDITION❑ DESTRUCTION❑ C WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION m—. PUMP REPAIR REPLACEMENT❑ Sewer Lines Pit Privy - DISTANCE TO NEAREST: Septic Tank .+ Sewage Disposal Field�S� 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 ❑ DRILLED pia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing T ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout I E] DISPOSAL ❑ OTHER Other Information i ❑ GEOPHYSICAL Surface Seal Installed By: [ PUMP INSTALLATION: Contractor Ile 111!11 Ist A r Type of Pump H.P. s ❑ State Work Done ` i PUMP REPLACEMENT: PUMP REPAIR: ❑ State Work Done 1 Approximate Depth I DESTRUCTION OF WELL: Well Diameter Describe Material and Procedure I t I hereby certify that I have prepared this application and that the work will be done in accordance with San"permit 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 fois issued, I shall not employ any person in such manner as to become subject to workman's compensation la 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 will call for a Grout In pecii Ior to groutin and a final inspectio ' Title: Date: Signed X (Dra�Pllt Plan on Re erse Side) i FOR DEPARTMENT USE ONLY PHASE I d` Bate 0�r`' Application Accepted B Additional Comments: Phase II Grout Ins clion h se 111 f Inspection 01 Inspection By k�-�?- Date J Inspection By J ate t Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE EACH ❑ January-1 &Received By January 31 ❑ July 1 8 ReceiveR�EMITuIy 35 BASE EXPLANATION BILLING REMITTANCE AMOUNT OUE CHECKED DATE DATE REMITTED AMOUNT $ D 0 FEE 45 LESS PRORATION _ PLUS PENALTY' OTHER OTHER Date Receipt No. Permit No. .Issuaria Date Mailed Delivered . Received by .. •APPLICANT—RETURN'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 200s STOC!<TON,CA 95201 kik-... ..