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! k App icatlons Will Be Processed WhdAdbmitted Properly Completed. Be Sure To Sign The Application. FOR`�+FFICE USE: � X` t 1 APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL SIGN JC'",Q01N ENV R NMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) HEALTH DIS I Kiu f 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 Heelth District. (oExact Site Address ' 17 3) ^�: J! City/Town Owner's"Name -1-0-,AV s c tl i- J G Phone A11A Address ' City nJ Contractor's Name . v License# ,01 Business Phone: - t3 Contractor's Address _ 3' �>L Alw .. - 'Emergency Phone • — Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes tula� No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIONDESTRUCTION❑._ - WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT13 I DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 7 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 19 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 C>J ❑ GEOPHYSICAL - I Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H,P. PUMP REPLACEMENT: ®,State Work Done PUMP REPAIR: ❑ State Work Done 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. 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 viftall for a Gro t Hsps ion prior to grouting and a final inspe t Signed X Title: 7�� r Date: '-� (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date Additional Comments: Phase II Grout Inspection Phase ill Final Inspection Inspection By V's Date Inspection By ° Date � . i Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July S &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED I AMOUNT FEE q (� LESS PRORATION PLUS PENALTY OTHER ' OTHER ,,,,;....r.�✓ y-r - - Received by - Date I Receipt No. - Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2409 STOCKTON,CA 952 t