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Applications ill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFI�E`USE� APPLICATION r. (For Non-Transferable, Revocable, Suspendable) �1e Ca n1 ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) ((,d ,;VTER QUALITY o Appl ication is hereby made to the San Joaquin Local Health District fora permit to construct arid/or install the work herein described.This application is made in compliance with Pan Joaquin Coun y Ordina a No. 1862 and d the rulesand regulations of the San Joaqui o Health District. Exact Site Address �([ko 6✓��-4 //00� �p� City/Town c� Owner's Name t.1 a *� _ Phone Address City Contractor's Name License# Business Phone Contractor's Address Emergency Phone f Is Certificate of Workman's Compensation insurance on File Wi SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION 1:1 . WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy C ` Sewage Disposal Field -Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well 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 El GEOPHYSICAL Surface.Seal Installed By: Q PUMP INSTALLATION: Contractor ' 0 Type of Pump 1* H.P. / PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: State Work Done JC JN ! DESTRUCTION OF WELL: Well Diameter Approximate Depth r ) 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. 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I ill all for a Grout Inspection prior to gro fin nd a fin nspection. 4 Signed r - Date: 'Y ' (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE ] Application Accepted By Dated Additional Comments: _ Phase 11 Grout Inspection Phase III Final Inspection o Inspection By Date Inspection By Date Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑'July 1 &Received By July 31 ) BASE EXPLANATION - BILLING -FIEMITTANCE $ REMIT DATt DATE REMITTED AMOUNT DUE CHECKED r AMOUNT FEE LESS = PRORATION PLUS PENALTY OTHER OTHER 6 4b Received by Date ReceiPt No, `Permit No. Issua ce to Mailetl Delivered APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES.a 1601 E.HAZELTON AVE.;P.O.Bot 2009 STOCKTON,CA 95201 � ..