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Applications Wilt Be'Processed When Submitted Properly Completed.Be Sure To Sign The Application. .. � i -FOR oPFrcE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) l"'C ENVIRONMENTAL HEALTH PERMIT PUMP&WELL �I OMPLETE IN TRIPLICATE) ((QS Zp rte-v a—-s5$7zg�YATER QUALITY ,Zp 01 _390--s2_ ,plication is1hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordin nce No.1862 and the rules an reg latieytS of the San Joaquin Local Health District. Exact Site Address a�.%! ��-�cn ,I� -f4 l��' y Qilty/Town _ QJL Owner's Name Phone_ Address City_ C�ntractors Name License D Cdntractor's Address �� Business Phone mergency Phone Is.,Certificate of Workman's Compensation In urance on File With SJLHD? Yes� X_ No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR REPLACEMENT❑ r DISTANCE TO NEAREST: Septic Tank f r00 Sewer Lines Pit Privy �f Sewage Disposal Field... /00 `—Cass pool/Seepage Pit Dther p Property Line Private Domestic Well _ Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation — 6❑ DRILLED Dia.of Well Casing "��C� _ ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION XGRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout .T ❑ DISPOSAL ❑ OTHER _ Other Information -� ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor i Type of Pump _ H.P. PUMP REPLACEMENT: D State Work Done PUMP REPAIR: ❑ �5tate Work Done STRUCTION 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. t 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 taws of California." Contractor's hiring or sub-contracting 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 taws of California." I will 11 for a Grout Inspectio rior to groutin+ad final inspection. Signed X Title: Date:(Drawan on Reverse Side) PHASE I FOR DEPARTMENT USE ONLY tt11,,..,.,,,, Application Accepted By ._ _ _ _ Date`•' Additional Comments: Phial I rout Inspection P e II Ina/ Inspection Inspection By Dat �� Inspection By 4' `.• Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑.January 1 3 Received By January 31 ❑ July 1 &Receivetl By July 31 REMIT ' BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ' DATE DATE REMITTED AMOUNT FEE 00 LESS PRORATION ' PLUS --� PENALTY OTHER OTHER - -- �-� Received by Date Receipt No. - Permit No. Issuance-Date Mailed Delivered ENVIRONMENTAL HEALT APPLICANT—RETURN ALL COPIES TO: H PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Box 280% STOCKTON,CA 95201 - 1