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r _ f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE;USE: APPLICATION —(For Non-Transferable, Revocable,Suspendable) POMP&WELL "Q ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY .•.,r: . „ n+ ,f � �' - .. "• 1 Application is hereby made totheSan Joaquin Local Health District fora permit toconstruct and/or install the work herein described.Thisappiicationi�I made in compliance with San Joa pin County O diinance fNo. 180 and the rules and regulations of the San Jo Local aI istrict. �� ► Exact Site Address �� L A V 2S71-d/ City/Town fr r Owner's Name X. Phone' Address �' City Contractor's Nam Licensed Bu ness Phone Contractor's Addres Emergency Phone l ern. L Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL&'DEEPEN ❑ r RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION&;–,�UMP REPAIR❑ i' REPLACEMENT❑ Ile , DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field r5� / Cesspool/Seepage Pit Other th Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL �l ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation O ESTiC/PRIVATE ❑ DRILLED Dia. of Well Casing [f1 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION !' 11 GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION &-'ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other-Information ❑ GEOPHYSICALSurface Seal Installed7By' PUMP INSTALLATION: Contractor Type of Pump H.P. 5~� PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ 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 Y' ordinances,state laws, and rules and regulations of the San Joaquin Local Health[7istrict. J , 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 laws of California." Contractor's hiring orsub-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 C04 for rout Inspection prior to grout g and a final Inspection. +r Signed X Title: Date: raw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I C Application Accepted By `� a v Date �`�� Additional Comments: k05: P as II-Grout Inspection Phase III Final inspection oz� !�� spect y Date S /4'� -->- - Inspection By Date �p f L Fee Is Due: 11ANNUALLY ElPER UNIT ElPER SITE ElEACH '❑ January 1 &Received By January 31 ❑ July 1 8 deceived 8y July 31 REMIT BASE' EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED Q�i DATE DATE REMITTED AMOUNT. FEE U U LESS - PRORATION - PLUS L a PENALTY i OTHER 7 47 OTHER - N -rS r`59 4o LV .._— Received by Date Receipt No.- - --Permit No.s _ _-. Issuance Date Mailed Delivered' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.too■2009 STOCKTON,CA 95201 .