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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) l PUMP&WELL f - ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance wSan Joaqui C9unty Ordmanc No. 186 d the r les and/rouI ions/ the San Joaquin Local He,@1V1 District. Exact Site Address Cf• Owner's Name f Phone ._�� 09 Address city Contractor's Name , r Business Phone� 7 i Contractor's Address Emergency Phone — C, Is Certificate of Workman's CompensationInsu ante on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN I]-';' RECONDITION❑ DESTRUCTION❑ �' WELL CHLORINATION ❑ WELL ABANDONMENT ❑ 'OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑. DISTANCE TO NEAREST: Septic Tank J�GYJ Sewer Lines Pit Privy ; Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL p ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 011 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing W IRRIGATION GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION [VOTARY 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 's 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 J aquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r 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, l 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 _ - - - permit is issued, I shall employ persons subject to workmari's compensation laws of California." f I will call for a Grout In ction prior to grouting and a final ins pe ion. - - — - - Signed X L d tT Date: 7 (Draw Plot Plan on Reverse Sid RZDRTMENT E ONLY PHASE I � � � Application Accepted By ' �-^� Date U Additional Comments: Phase 11 Grout Inspection 1Final Inspectio Inspection By Date .. inspection i DateQ Fee Is Due: F-1ANNUALLY El PER UNIT El PER SITE El EACH 13January l & eceived By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION - DATE DATE REMITTED AMOUNTDUE CHECKED 3 S AMOUNT FEE LESS PRORATION PLUS PENALTY, OTHER OTHER e . G7 �y-�'- Received by ' - Date Receipt No. Permit No. Issuance Date Mailed Delivered a APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 3