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Applications WIII Be Processed When Submitted Property Completed.Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable,Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT -APLETE IN TRIPLICATE? WATER QUALITY.,; ..,ilication is herebymadetothe San Joaquin Local Health District for a permit to construct ard/or instal I the work herein described.This application is S made in compliance with San Joaquin Co my_Orf Ina e No. 862 and the rules and regulations of the SanJoaquinLocal Health District. Exact Site Address .�a-fl -n, /J-y'D City/Town Owner's Name _ Phone Lill Address Citll��S'7 Contractor's Name License# / Business Phone"' r��I Contractor's Address Emergency Phone Is Certificate of Workman's or; ensation insurance on File With SJLHD? Yes No „ TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ - t WELL CHLORINATION ❑ WELL ABANDONMENT C3OTHER 13is PUMP INSTALLATION '�PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy - Sewage Disposal Field Cesspool/Seepage Pit Other Vv- Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ 1iy03 TRIAL ❑ 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 Sort a Seal installed By � PUMP INSTALLATION: Contractor $,� �� Q Type of Pump_ H.P. PUMP REPLACEMENT: ❑ State Work Done - PUMP REPAIR: ❑ State Work Done MRUCTION OF WELL: • Well Diameter — Approximate Depth C 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 t 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, 1 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 WIII Grout Insp i n ri r to routing and a final inspection. Signed Title: __ c s — Date: 0 ' (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I ,/ Application Accepted By - --- �— Date Additional Comments: Phase II Grout Inspection nal Inspection inspection By Date Inspection By Date --- l - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1&Received By January 31 ❑ July 1&Recelved By July 31 REMIT 'BASE EXPLANATION BILLING REMITTANCE 5 AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No.- Issuance Date Mallets Delivered I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SFRVICES 1601 E,HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201