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u w m e milted Pro erl Completed. BeSure �oslgn IncAPPI,cauy Appldj ns Will Be Processed p Y LLS q APPLICATION r((COMPL MINTRIPLICATE) OOT 7 I Q Q d 1(FBPNon-Transferable, Revocable,Suspendable) pUMP&WELL „ I J ONMENTAL HEALTH PERMIT SAN JOAQUIN �� HEALTH DISTRICT WATER QUALITY ! Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is made in compliance with San Joaquin Count Ordinance No. 1862 and the.rules and regulations of the San Jo�aq in Lo al Health District. Exact Site Address GL 'ua- ►ie- City/Town Phone Owner's Name City 4 Address S ` License# usiness Phone — Contractor's Name - Emergency Phone Contractor's Address >LNo Is Certificate of Workman's Compensation Insurance on File With SJLHD4 Yes ION TYPE OF WORK (CHECK):. NEW WELL K— DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WE__LL,CHLO.RINATION p-,�,,,,,,.•WELL•ABANUONMENT D,,,�,,,,OTHER PUMP 1NSTALLATIOi PfJNiP REPAIR , REPLACEMENT❑ Sewer Lines Pit Privy t DISTANCE TO NEAREST: Septic Tank Other Sewage Disposal Field /�S� Cesspool/Seepage Pit 4 _ Property Line_- Private Domestic Well_ Public Domestic Well OF WELL INTENDED USE TYPE 1' y ❑ TRIAL INDUSCABDia. of Well Excavation i LE TOOL r; I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑'DRIVEN-- Gauge of Casing ❑ IRRIGATION r� 13 GRAVEL PACK Depth of Grout Seal f ❑ CATHODIC PROTECTION ❑"ROTARY Type of Grout ❑ OTHER Other Information El DISPOSAL 13 GEOPHYSICAL Surface Seal`nstalled By: PUMP INSTALLATION: Contractor YP P H.P. T e of Pum 11 State Work Done PUMP RE } M f PLACEMENT: --- t PUMP REPAIR: State Work Done Well Diameter Approximate Depth DESTRUCTION OF WELL: � Describe Material and Procedure 3 I F - I - pplication and that the work will be done iri accordance with San Joaquin County I hereby certify that l have-lTrepared`this a ordinances, state laws, and rules and reegulations of the San Joaquin Local Health Distr.ict. 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." i Contractor's hiring or sub-contracting signature certifies the iollowingr'`{certify that in the performance of the work forwhich this x k permit is issued, I shall employ persons subject to'workman's compensation laws of C.l fornia." r I will III for a Grout Inspection prior to grouting and a final inspection. ,. It f r. i Title: Dater Signed X (Draw Plot Plan on Reverse Side) t �- f . t FOR DEPARTMENT USE ONLY # PHASE I Date I�~ ` Application Accepted By � Additional Comments: l I4 Sri l hase Il t Inspection y� t se Irl final fns ectioiQ ( ate L +i" Inspection By 'Date Inspection B Sa` ids� �e- r Fee Is Due: ❑ ANNUALL iJ'PER UNIT PER SITE ❑ EA H El January 1 &Received By January 31 ❑ July 1 R fleceiv July 31 REMIT r _BILLING REMITTANCE AMOUNT DUE CHECKED BASE - EXPLANATION DATE DATE REMITTED AMOUNT FE LESS PRORATION PLUS - - PENALTY - - OTHER OTHER x Date Receipt No Permit No.' Iss nce ate Mailed Delivered Received by ..� k. APPLICANT—RETURN ALL COPIES TO: ;ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201