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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, I g t FOR OFFICE USE: APPLICATION /G* Non-Transferable,Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT t 'F (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby madeto the SanJoaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is f 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 r Cityjown Owner's Names'Y�_��'t' �d.d-O'1'��Z-+.- Phone r�SS�(�`- ©17 �— Address -- City _ Contractor's Name l License#..a.ry�_ a"4I 1 Business Phone 3S i c y Contractor's Address U Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN 13 RECONDITION 11 DESTRUCTION❑ UJ WELL CHLORINATION ❑ WELL ABANDONMENT ❑' OTHER ❑ 'PUMP INSTALLATION ' PUMP REPAIR❑ REPLACEMENT❑ l DISTANCE TO NEAREST: Septic Tank Sewer Lines _ Pit Privy Sewage Disposal#laid Cesspool/Seepage Pit Other Property Line_ Private Domestic Well Public Domestic Well - INTENDED USE TYPE OF WELL ❑ IND TRIAL ❑ CABLE TOOL Dia.of Well Excavation OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ pRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth,of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY -Type of Grout ❑ DISPOSAL ❑ OTHER Other Information S ❑ GEOPHYSICAL .,¢_. Surface Seel Installed By: 6 PUMP INSTALLATION: Contractors rii�.r .�.� X�a.e.�- Type of Pump �� H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: P State Wolk Done DESTRUCTION OF WELL: 'Well Diameter Approximate Depth Describe Mi aterigl,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 signaturedertilies the following:"I certify that in the performance of the work for which th is permit is issued, I shall employ persons subject to workman's compensation laws of California:' I will call or a rout Inspecti In prior to grouting end a final inspection. cr'� Signed X � Title: ',_�1'�� Date: (Draw Plot Plan on Reverse'Side) FOR DEPARTMEN7,USE ONLY PHASE I Application Accepted By Date Additional Comments: Phase 11 Grout Inspection net Inspection 2 Inspection By Date Inspection By _ Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31" ❑ July t &Rece3vee By July 31 REMIT BIELING REMITTANCE $BASE EXPLANATION ATE DATE REMITTED AMOUNT DUE CHECKED ' Q AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER � 3- s 3 Received Cy Date Receipt No. Permit Nolas ante ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 164111 E.HAZELTON AVE-P.O.Boa 2009 STOCKTON.CA 952111