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Applications Will Be Processed When Submitted P'%.krly�omplerea. meaura kv„y,g FOR OFFICE USE: APPU „A •�Rrr••��• - TION / �[a1ryC�AA (For{Non-Transferable, Revocable,Suspendable) / PUMP&WELL (/ ENVIRONMENTAL HEALTH PERMIT ! (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is made in compliance with San Joaquin County Ordinate_ Not.1862 and the r es and egulations of the San Joaquin Local Health District. Exact Site Address po City/Town Owner's Name l— a' Y Phone Address City Contractor's Name 26M24 AZ License# Business Phone— qn4 Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With LHD? YesNo 4 TYPE OF WORK (CHECK): NEW WELL DEEPEN ElRECONDITION 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 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 ❑ GEOPHYSICAL Surface Seal I ailed By: PUMP INSTALLATION: Contractor 00 Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done— PUMP one PUMP REPAIR: State Work Done CX0- 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of theationi or which this permit is issued, I shall not employ any person in such manner as to become subject to workman's comp lawsof 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 will call for a Grout Inspecti rior "routing nd a 'nal inspection. Signed le: — Date: (Draw Plot an on Reverse Side) FOR DEPARTMENT USE ONLY l PHASE IJ Date Application Application Accepted By Additional Comments: Phase II Grout Inspection as II Final Inspection Inspection By �� Date Inspection By ate i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &R ived By January 31 El July 1 &Received By July 31 REMBASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED PATE DATE REMITTED AMOUNT FEE dEL. LESS PRORATION PLUS - PENALTY OTHER OTHER Received by Date Receipt No. f Pe mi o. Issuanceloate I Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201