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— ApplicationsWillBeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFF_10E USE: II APPLICATION J (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL , (COMPLETE IN TRIPLICATE) !� WATER QUALITY Application 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 Cou ty dinancNo. 86 and the rules and regulations of the San J aqui L c I Health District. Exact Site Address C City/Town .5 Owner's Name Phone Address City Contractor's Name r 1 �� License#_3ya�Business Phone Contractor's Address Emergency Phone - Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELL Cg-- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ Ii \31 DISTANCE TO NEAREST: Septic Tank /10Q Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property LinePrivate Domestic Well-116iLt✓Public Domestic Well t INTENDED USE-, - TYPE OF WELL ❑ INDUSTRIAL ��/ I CABLE TOOL Dia. of Well Excavation JXDOMESTIC/PRIVATE �� ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION I ❑ GRAVEL PACK Depth of Grout Seal slzo ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information )) ❑ GEOPHYSICAL Surface SealInstalledBy: ; PUMP INSTALLATION: �! Contractor � . Type of Pump__q� H.P. PUMP REPLACEMENT: i ❑ State Work Done PUMP REPAIR: �" ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure it I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 ordinances, state laws,l'and rules and regulations of the San Joaquin Local Health District. +fig Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit +t is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 11 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." 1 will atl for a Grout Inspection prior to grouting and a final inspection.' Signed X Title: Date: j� (Draw Plot Plan on Reverse Side) a FOR EPARTM NT USE ONLY PHASE I ;! ,4117f Application Accepted By II /1' �^ Date v Additional Comments: I� Phos 11 Grout inspection ase 1 Final Inspection Inspection By hh Date Inspection By �./!� Date 17//� Fee Is Due: ❑ ANNUALLY II❑ PER UNIT ❑.PER SITE _r❑_EACH ❑ January 1 &Received By January 3d ❑ uJ ly 1 &Received 9y July 31 a REMIT i BASE:i T EXPLANATION AMOUNT DUE CHECKED �Y BILLING REMITTANCE $ GATE RATE REMITTED AMOUNT r FEE LESS PRORATION PLUS I� PENALTY OTHER p OTHER li 99 —79- -7g-11--),--- Received by. Date Receipt No ermit No, Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 fes.