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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I FOR OFFICE USE: CQ 1,0_f- _A APPLICATION WP � 1 (For Non-Transierable, 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 wo(,k herein described.This application is made in compliance with San Joaquin County Ordinance tjo. 1882 and the rules and regulations of the San J�o� uln o al He th District. Exact Site Address / ��7� -� � >��s _ City/Town Owner's Name tic 4- Phone Address City I f Contractor's Name e License -714-- Business Phonelml _ 67, 74 7 1 r� Contractor's Address Emergency Phone a Vl Is Certificate of Workman's Compensation Insurance on File ? Yeses No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECON ITiON❑ DESTRUCTION 0 r WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ o PUMP REPAIR E REPLACEMENT$ ii DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well i 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 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER _ Other Information ❑ GEOPHYSICAL Surface Seal InstalleJ,By: PUMP INSTALLATION: Contractor _ • ^"— Type of Pump- . r- r- H.P. N PUMP REPLACEMENT: F State Work Done i PUMP REPAIR: ❑ State Work Done . DESTRUCTION OF WELL: Well Diameter Approximate Depth i Describe Material and Procedure Q 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 forwhich this permit is issued, I shall not employ any person in such manner as to become subject to workman's comiensation laws of California." j 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 cal for a Grout Inspection prior to grou ' and fiVal I section. I Signed X - e: Date: 60 < /rlyhraw Plat Plan on Re rse Side FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date Additional Comments: Phase II Grout Inspection a Inal Inspection -=Inspection By Date Inspection By Date 2 —,9 I I Fee 19: tie. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &,Received By January 31 ❑ July t &Received By JUly 31 - BILLING REMITTANCE $ ` REMIT BASE EXPLANATION n AMOUNT DUE CHECKED DATE., ti DATE REMITTED AMOUNT FEE' "�.. 44C� .' LESS PRORATION PLUS !: PENALTY OTHER 3 a OTHER _ b Received by Date Receipt No.- Permit No. lbsuanck Date li Mailed Delivered i ' -APPLICANT—RETIJRN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 .