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rr Applications Will Be Processed When Submitted Properly Completed. be !sure FOk'OFFiCE USE: d� APPLICATION a� (For Non-Transferable, Revocable,Suspendable) PUMP&WELL �/�' ^ 1 ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) U WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with Sari Joaquin County Ordinpancee.N . 1862 and the rules and regulations of the San aq��ocal Health District. Exact Site Address 55,5" City/Town �/.b�—u _ '` Phone 3 3 �- 3 0 7 5� d Owner's Name Address City ` License It stn�- -2 2-3 Business Phone 3 Contractor's Name �f66��G �— Contractor's Address /3 O �J. � - ' " J Emergency Phone } Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No + TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL. CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL i .y Dia. of Well Excavation 11DOMESTIC/PRIVATE ❑ DRILLED i t Dia. of Well Casing 1&4pOMESTIC/PUBLIC ❑ DRIVEN k Gauge of Casing ° RIGATION ❑"GRAVEL PACK Depth of Grout Seal ❑ I 11 CATHODIC PROTECTION ❑ ROTARY �„�..� Type of Grout a ❑ DISPOSAL ❑ OTHER I Other Information 1 Surface Seal Installed By: ❑ GEOPHYSICAL p ,` W PUMPS'INSTALLATION: Contractor " '- / Type of Pump H.P. , 1 _ PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 2-State Work Done_d ' S17 DESTRUCTION OF WELL: Well Diameter ` Approximate Depth Describe_Material-and-P�Jacedure ) 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:"l certify that in the performance of the work for which this permit 1 is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." s Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this i permit is issued, I shall employ persons subject to workman's compensation laws of California." I w' all fora Grout In ction prior to grouting and a final inspection. Signed X (Draw Plot Plan on Rover Side) i FOR DEPARTMENT USE ONLY PHASE ' Date Application Accepted By Additional Comments: Phase It Grout Inspection Ph e i Final pection Inspection By D Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT i FEE , l LESS f PRORATION PLUS PENALTY I_ OTHER OTHER ' r Date Receipt NoPermit No. issuance Date Mailed Delivered j. Received by - � APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 16Q P,HAZELT AVE.,P.O.Box 2009 STOCKTON,CA 95201.