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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) PUMP&WELL 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 with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Addressli!i.w�X91 City/Town Owner's Name<�C� tO � •u.c�c+.t1v� Phone _ Address City-:24-6-r, Contractor's Name License#35 x}71- Business Phon I Contractor's AddressEmergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No *TYPE OF-WORK (CHECK): NEW WELL❑ DEEPEN ❑ -RECONDITION❑- `DESTRUCTIO,N,❑ .-WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION 6-� PUMP REPAIR } 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 ❑, INPSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 'DOMESTIC/PRIVATE ❑ DRILLED Dia. 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 C Surface Seal Installed By: PUMP INSTALLATION: Contractor �� P•�c Type of Pump l H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done I DESTRUCTION OF WELL: Well Diameter Approximate Depth I Describe Material and Procedure I i 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. Home owneror 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 permit is issued. I shall employ persons subject to workman's compensation laws of California." I I will alhil r a Grout Inspection prior to grouting and a final inspection. Signed , Title: _ - ._ Date: �f"� ' ` (Draw Plot Plan on Reverse Side) I FOR DEPARTMENT USE ONLY PHASE 1 Application Accepted By--- I _ r Date Additional Comments: I ' Phase II Grout Inspection Pha til nal Inspection D Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE 11 EACH El January 1 &Received By Janu y 31 ❑ July 1 &Received By July 31 f REMIT - BASE EXPLANATION BILLING REMITTANCE . $ AMOUNT DUE CHECKED DATE DATE, REMITTED AMOUNT FEE - ~ LESS PRORATION ' Ptus PENALTY OTHER OTHER - Received by Date- '" Receipt No. " - Permit No. - Issu nice 11he Mailed Delivered' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201`.' '*" X cvs A-