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Applications Will Be Processed When Submitted Properly Co I u Ai Tial A I tion. F,OR 000E USE:. APPLICATIO U VI i ' (For Non-Transferable, Revocable, endep - 1979 I UU g PUMP&WELL I ENVIRONMENTAL HEALTH.PE:RMIT (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JOAQUIN LOCAL Application is hereby made to the San Joaquin Local Health District for a permit to construct anWAL-11li tYlerv4tArkTFierein described.This application is ..Q made in compliance with San Joaquin County Or inance No. 1862 and the rules and regulations of the San J a uin Loca Health District. Exact Site Address City/Town .. Owner's Name Phone z g : Address City Contractor's Name _ License# Business Phone W 7 Contractor's Address _ SL6� U Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 0 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout © DISPOSAL ❑ OTHER Other Information ;1? ❑ GEOPHYSICAL Surface Seal Installed By: � PUMP INSTALLATION: Contractor Type of Pump H,P, PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: IR 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 1 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 will I for a Grout Inspection prior to grouting and a final inspection. !� Signed X Title: Date: (Draw Plot Plan on Reverse Side) ORD PARTMENT USE ONLY PHASE IQ - 9 Application Accepted By Dalo Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By Date k Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE - EXPLANATION BILLING REMITTANCE $ k AMOU61T DUE CHECKED - �• DATE DATE REMITTED - � AMOUNT FEE r S F LESS PRORATION - PLUS PENALTY OTHER OTHER i C1 ~> >Lis1( mReceived by Date-' i.— Receipt No. Perrni!No. Issuance Dae Mailed Delivered APPLICANT—RETURN ALL COPIES TO:-:, ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE.r P,O.Box 20D9 .STOCKTON,CA 95201- ..