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Applications Will Be processed When Submitted Properly C;omplill tie bure t o Sign 1 ne Applicanon. FdR OPr, E USE: APPLICATION I�Niiiiiior Non-Transferable, Revocable, SuspendableP-d ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Appfication is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin FocaliHealth District. Exact Site Address 6 City/Town f;,l1 bL_1 _.._ Owner's Name �C�J �'r�7�f�ode?.. Phone _14 il 17 7- 7 Address - - /�5 Y06-.-55'.,��ILaG�. -- Contractor's Name License# _ Business Ph one _ _ I Contractor's Addresshv' X 'f Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJI_HD? Yes ._ _ No TYPE OF WORK (CHECK): NEW WELLP DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ W— WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ I DISTANCE TO NEAREST: Septic Tank /an. f�- Sewer Lines Pst Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL V ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of W0Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing "nilL ❑ DOMESTIC/PUBLIC1❑ DRIVEN Gauge of Casing - © IRRIGATION yw GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ri -e .9 u ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor — Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done --- A 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 C ordinances, state laws, and rules and regulations of the San ,Joaquin Local Health District. C Homeowner 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 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 laws of California." I will call for a Grout I pection prior to grouting and a final inspect Signed X it. Date: (Draw Piot Plan on Reverse Side t• FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date Additional Comments: ase I t Inspection Phase II 1 Inspection Inspection By Date Inspection Sy — Date � Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 T REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE -- LESS PRORATION - PLUS PENALTY OTHER OTHER Received by� Date Receipt No. Permit No Issuance Date Mailed Delivered APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201