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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOIA OFFICE USE: APPLICATION (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 District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address ✓� �2� f�/J [�J� �1 -�� City/Town -�J �4/1�GTy�/1 Owner's-Name . -'�f�7 / /-1 TA L7 Phone /4�"r / t r Address / city TG C& Contractor's Name r J_z� ''h G -License#, 7I GG Business Phone_ Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insura ce on File With SJLHD? Yes No d TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONK DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ �f 1 REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank ADO ? 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 pia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -tt ❑�{,`` DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing gyp+ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor '1 Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done , PUMP REPAIR: ❑'State Work Done DESTRUCTION OF WELL: WeII 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 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." f 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 wall I rout Inspection p ' r to grouting and a final inspection. Signed X Title: �iLc�. Date: (Draw Plot Plan on Reverse Side) i FOR DEPARTMENT USE ONLY 1 PHASE I Application Accepted By - Date Additional Comments: --� t� Phase 11 Grout Inspection Ph se III Final Inspection N / Inspection By 1 If� I; Date Inspection By s,—, Date f Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S17E ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ MOUNT DUE CHECKED DATE DATE REMITTED AMOUNT i FEELESS PRORATION , PLUS 1 / PENALTY [ j OTHER \,V, v'h. OTHER Received by Date Receipt No. Permit.No-- Issuance Date Mailed Delivered APPLICANT—RETURN-ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES "'1601 S.HAZELTON AVE.,P.O.Bow 2009 STOCKTON,CA 95701 A.