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� •c_.— App4 L llcations Will B13 Processed When Submittedproperly y, APPLICA ON FO"%'6FFICE USE: pUMp&WELL � ^� (For Non-Transferable, Revocable, Suspendable) , ENVIRONMENTAL HEALTH PERMIT WATER QUALITY application is istricttora permitto construct and/or install (COMPLETE IN TRIPLICATE) Application is hereby made to the San Joaquin Local Health Dthe work herein described.This ode in compliance with San Joaquin Count rdinance No.1862 and the rules and regulati Cis o ty/Town�t the SanfJoaquinf�ocal Health District. 0 1 IF•� I Exact Site Address C Phone —3 Owner's Name City1 Address Business Phone y� �� 6' License# �+ y F Contractor's Name Emergency Phone p ! Contractor's Address t�� No I� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ❑ DESTRUCTION❑ TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION � ❑ NDONMENT ❑ OTHER [3 PUMP INSTALLATION 13 PUMP REPAIR❑ WELL CHLORINATION WELL ABA REPLACEMENT❑ Sewer Lines Pit Privy DISTANCE TO NEAREST: Septic Tank Ce Cesspool/Seepage Pit Other Sewage Disposal Field c Well 4_C>_ public Domestic Well _1;1 Property Linl Private Domesti TYPE OF WELL P Y k INTENDED USE pia" of Well Excavation ❑ INDUSTRIAL EL-erABLE TOOL 13 DRILLED Dia. of Well Casing EF-5oMESTIC/PRIVATE Gauge of Casing 1- 0 DOMESTIC/PUBLIC ❑ DRIVEN 13 GRAVEL PACK Depth of Grout Seal 13 IRRIGATION Type of Grout L ❑ CATHODIC PROTECTION I ❑ ROTARY ❑ OTHER Other Information El DISPOSAL- Surface Seal Installed By: ❑ GEOPHYSICAL d Contractor H P PUMP INSTALLATION: Co - Type of Pump ❑ State Work Done i PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: Approximate Depth Well Diameter � DESTRUCTION OF WELL: �-, ;� Wel . 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District- Hing:"1 certify that in the periormance of the work for Home owner or licensed agent's signature certifies the followwhich this permit to become subject to workman's compensation laws of California." is issued, I shall not employ any person in such manner as _f Contractor's hiring orsub-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 inspection prior to grouting and a final inspection. Date:` Title: Signed )C (Draw Plot Plan on Reverse Side) i l FOR DEPARTMENT USE ONLY 1 . PHASE 1 (] Date e Application Accepted By t I t Additional Comments: ge 1 ina! Inspection # 9 c 4 hose out Inspection n 6/ E �y s D �� Inspection By ate inspection By Date (3 — PER U ❑ PER SITE ❑ EACH ❑"January 1 &Received By January 31 ❑ July t &Received By July 31 f { – REMIT Fee IS Due: ❑ ANNUALLY NIT❑ $ -AMOUNT DUE CHECKED >�. BILLING REMITTANCE l T _ BASE - EXPLANATION DATE DATE REMITTED AMOUNT I s 43y f FEE LESS t PRORATION - - F PLUS PENALTY ' F OTHER rt OTHER r Issuan a Date Mailed Delivered Receipt No. 'Permit'No. Received by� � Date � 1g01 ErHAZELTON AVE:.P.O.Box 2009. STOCKTON,CA 45201 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL-HEALTH PERMIT/SERVICES ,�