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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. '5- FOR OFFICE USE: APPLICATION La! 04 tw Non-Transferable,Revocable,Suspendable) PUMP&WELL i ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made 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 with Sawn4o�agquin County Ordinance No. 1862 andel the r es and regulations of the San Joaquin Local Health District. Exact Site Address �i:tv.r- 6/i /ll/ -+r'�ZCitylfown :Zu !/ Owner's Name IIOJAO Phone Z7/ Address ' /G City Contractors Name l.ti�r,xt� D.2y14A, ' CO License It ?�t'�•.Business Ph ne ,32-7932 Contractor's Address 36n 3 KIZ Qdu '-71JP10«` Emergency Phone I Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes�! No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Zamz: Sewer Lines Pit Privy Sewage Disposal Field /100 Cesspool/Seepage Pit Other t Property Line Private Domestic Well Public Domestic Well }, INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation 12 .DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC I❑ DRIVEN Gauge of Casing f/ ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of GroutL- ❑ DISPOSAL ❑ OTHER Other Information 0 GEOPHYSICAL 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 apd regulations of the San Joaquin Local Health District. Home owner or licensed agent's slgnature 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:' Contrector's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call f r Grout 1 spection prior to grouting and a final Inspection. Signed X TJtle: —Q � Date: ///�L/ (Draw Plot Plan on Reverse Side) - J FOR DEPARTMENT USE ONLY PHASEI. - - e/2 Application Accepted By Dat Additional Comments: Ph a 11 out Inspection P ase III Final Inspection Inspection By� A Date�%r•l`�' Inspection B Date Fee IS Due: ❑ ANNUALLY [] PER UNIT, ❑ PER SITE ' ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 d Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE s AMOUNT OUE CHECKED DATE DATE REMITTED AMOUNT FEELESS 3 PRORATION PLUS PENALTY OTHER OTHER B Y � Received by Dale Receipt No Permit No. Inuilme Dae Mailed . Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.P.O.Bot 1009 STOCKTON,CA$5201