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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. "4eD.!,FICF,USE: APPLICATION ' (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT. PUMP&WELL (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 applicati h made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health Distfict. Exact Site Address 3 1a63 li4u w ^ m!� 1— - City/Town s Owner's Name ST0 C—L Phone tt^ ; i Address 3 ] �. City 5t k-k-1. Contractor's Name License#_3_4 q2_0 Business Phone s Contractor's Address A5 ZO w+r Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL 19- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r WELL CHLORINATION 13WELL ABANDONMENT El OTHER -- PUMP INSTALLATION 19 PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank dVQ-V-- IQ Sewer Lines Pit Privy- L Sewage Disposal Field Cesspool/Seepage Pit Other I Property Line 50' Private Domestic Well Plc Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 2�.DOMESTIC/PUBLIC ❑ DRIVEN R Gauge of Casing t ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION I5 ROTARY _, Type of Grout ❑ DISPOSAL ❑ OTHER Other Information Ste' ❑ GEOPHYSICAL Surface S al Installed By: } PUMP INSTALLATION: Contractor L/v Type of Pump 5" j r;lf H.P. -. PUMP REPLACEMENT: ❑ State Work Done ' PUMP REPAIR: _ ❑ State Work Done 1 r DESTRUCTION OF WELL: Well Diameter `Approximate Depth ' - 6 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 I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit- s issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." o"Iractor's - g or -contracting signature certifies the following:"I certify that in the performance of the work for which this permit is sued, I shall mploy persons subject to workman's compensation laws of California." t I ill c I r rout I ection pri grouting and a final inspection. JJJJJJ�� l��l Signe Title: �yl as Date: —(Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I 1 b� Y Application Accepted B Date Additional Comments: Phas4;11rout Inspection) g --,Phase III Final Inspection Ins ect)'on By a e 1�-�- 0 0 Ir{spection By. Date �e.Y►�n C_k--/v� Y�tto c rd n� se��f�u V� Fee IS ❑ ANNUALLY P1 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE - $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE •c C/ LESS PRORATION - r . 4 PLUS PENALTY OTHER r OTHER - Received by Date Receipt No Permit No. Issu nce Da Mailed Delivered F APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMIT/SERVICES .,; 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201