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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION i (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) 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 Health District. Exact Site Address _ City/Town Owner's Name Phone Address City Contractor's Name License # 7� � Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compens tion Insurance on File With SJLHD? Yes No S TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION LJ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIA.De REPLACEMENT❑ j DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 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 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal T ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: tI PUMP INSTALLATION: Contractor C 11} �Type of Pump H P S� PUMP REPLACEMENT: State Work Dono PUMP REPAIR: ❑ State Work Done .01 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 forwhich 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 p-erformance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. Signed X Title: Date: „ } ��DrawPlot Plan on Reverse Side) E FOR DEPARTMENT USE ONLY PHASE I C ' Application Accepted By— — Date AO � / Additional Comments: U Phase II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By ate Fee IsrDue: ❑ ANNUALLY` - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jul eceived By July 31 BILLING REMITTANCE $ REM#T BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER _I �.� 1 ^, `]9-1133 yds Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered :Fh APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - -1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201.