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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. .FOR OFFICE USE: G'I APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL r " ENVIRONMENTAL-HEAL-TH'PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY _ _ r r 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 Qrdinance No.862 and the idles and regulations.of the.San Joaquin Loc I Health District. Exact Site Address .f g9 0/ �\ -of Law]C �2CKd C ty/Town ... Owner's Name 1` a. � Phone Address b� (' f City Contractor's Name License fr91/4 Business Phone !1 Contractor's Address , Emergency Phone' . 't Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No T TYPE OF WORK (CHECK): '�-NEW WELL -- DEEPEN RECONDITION -DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT � - OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ v REPLACEMENT❑ 1 + DISTANCE TO NEAREST: Septic Tank _ �� Sewer Lines Pit Privy Sewage Disposal Field_tSQ.:_^� Cesspool/Seepage Pit Other - — Property Line Private Domestic Well Public Domestic Well ^^�` INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation X LS Y2 k r,1Z DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C ❑ IRRIGATION- GRAVEL PACK .; Depth of Grout Seal 1 ❑ CATHODIC PROTECTION 'ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL } Surface Seal Installed By: Jp[�•�%K` 1 PUMP INSTALLATION: Contractor Type of Pump PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth , Describe Material and Procedure t ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County J ordinances, state'laws, and rules and regulations of the San Joaquin Local Health District. i 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." 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 per ns subject to workman's compensation laws of California." I F 4 -, -- I will I fora out pec n for to grouting and a final inspection. - Signed X Title: ,if A&- Date: {Draw Plot Plan on Reverse de) , i FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Q� �� Date Additional Comments: -Phas 11 Grout a ion/ [, P ase III Final Inspection Inspection By J� :D tf Inspection By-.- Date of '-o Fee Is Due. ❑ ANNUALLY EJ PEFi L7NIT '❑'PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 fREMIT BASE EXPLANATION _BILLING 4 REMITTANCE $ AMOUNT DUE CHECKED /` f1 DATE DATE- REMITTED a AMOUNT FEE LESS q. . PRORATION PLUS'- - - ► _ - PENALTY OTHER t OTHER Received by - Date - Receipt No. .---. Permit No. Fssuancd Date Mailed r Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 y