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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 1/ (COMPLETE IN TRIPLICATE) WATER QUALITY 4 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 J in County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address � City/Town Owner's Name Li.� � ✓� ('LL,� LJ f .r. Phone ¢ Address City Contractor's Name �C.f r License#_ S._ �j Business Phone Contractor's Address - { - Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? _Yes �� No TYPE OF WORK (CHEEK)NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑1 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑. PUMP REPAIR 13 REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Weil INTENDED USE TYPE OF WELL ❑ Irt§TRIAL ❑ CABLE TOOL Dia. of Well Excavation r 0-DOMESTIC/PRIVATE DRILLED Dia. of WeII,Casing ❑ DOMESTIC/PUBLIC '7"'1TDRIVEN a Gauge of Casing' ❑ IRRIGATION x ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout rG ❑ DISPOSAL ' ❑ OTHER Other Information ❑ GEOPHYSICAL _4 Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump: ..A H.P, PUMP REPLACEMENT:: -r ')❑ 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. 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." Contractor's hiring or sub-conlracting 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." I will call..,tor a Grout Inspection prior to grouting and a final inspection. Signed Xf Title: _6-CA.1UA-a-, _Date: :;1_61 J(Draw Plot Plan on Reverse Side) OR DEPARTMENT USE ONLY PHASE I % Application Accepted By Date Additional Comments: Phase II Grout Inspection P Final Inspection Inspection By -Date Inspection B Date Fee Is Due: ❑ ANNUALLY '❑ PER UNIT- - -©'PER SITE !'❑ EACH'- ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 _ -REMIT I BASE EXPLANATION-,y __BILLING . REMITTANCE- -� AMOUNT DUE CHECKED DATE DATE REMITTED L� AMOUNT47 ' FEE LESS PRORATION PLUS ' PENALTY r - ` OTHER g s - p.OTHER i �+ Received by - Date -Receipt No Permit No. - Isbuance D 1e Mailed'> Delivered- - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA 95201 Y