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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign Th Application. FOR OFFICE USE: APPLICATION V r � - ?5-1 Al2 Non-Transferable,Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT 4-O F_ :L-IS (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby metle to the San Joaquin Local Health District for a permit to construct and/or Install the work herein described.This application'is made in compliance wit�h/gan Jo/aqutn Count/y Ordinance o.1862 and the_ru_les and regulations of the Sen oaquin Local Health District. Exact Site Address�`f—�Cfr `^-' QJ1.5..0 s¢z�^ City/Town Owner's Name _ Phone 2Z Address S City Contractor's NameOi �o., ,.,.. License�/_(. Business Phone Contractor's Address �(p �--�— Emergency Phone Is Certificate of Workman's Compensation-Insurance on File With SJLHD?, , Yes No d TYPE OF WORK (CHECK): - NI=VJ.WELL❑ DEEPEN ❑ RECONDITION DESTRUCTIO,NNO IP �❑ WELL CHLORINATION 11 WELL ABANDONMENT • - OTHER 11la PUMP INSTALLATION 0---'PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines .Pit Privy Sewage Disposal Field .Cesspool/Seepage Pit Other Property Line Private porr)estic Well Public Domestic Well INTENDED USE - TYPE OF WELL ❑ IN TRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Die. of Well Casing lA ❑ DOMESTIC/PUBLIC ❑ DRIVEN Z Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _ ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL • ❑ OTHER Other Information ❑ GEOPHYSICAL '�(p yc Surface Seat Installed By: PUMP INSTALLATION: Contractor--?� o TYPe of Pump _ H.P. PUMP REPLACEMENT: ❑ State Work done PUMP REPAIR: 0 State Work Done DESTRUCTION OF WELL: Well Diameter--, Approximate Depth Describe Material and Procedu1.re I hereby certify that I have prepared this applj�ation and that the work will be done in accordance with San Joaquin County ordinances,state laws, and rules and regulat*S of the San Joaquin Local Health District. , Home ownerorlicensed agent's signature certifies the following:"I certifythat in the performance of the work for which this permit n^ is issued. I shall not employ any person in su6h manner as to become subject to workman's compensation laws of California." U, Contractors 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 subjeo to workman's compensation laws of California" I will I or a Grout Inspection prior to grouting and a final Inspection. Sign Title: At� Date: — 19, - (Draw•Plot Pian on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By , t' ! r Date Additional Comments: Phase 11 Grout Inspection _ Ph el at Inspection � 7/�9/ - Inspection By Date Inspection B Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT '❑ PER SITE 'n EACH ❑ January 1 d Received By January 31 ❑ July 1 a Received By July 31 REMIT BILLING REMITTANCE f BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT to FEE f7' LESS PRORATION PLUS PENALTY OTHER - OTHER y � o� Received oy Date Receipt No. Permit No. Iwuance7 Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201