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„'"Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. FOR 0FF10E USE: APPLICATION ;(For Non-Transferable, Revocable, Suspendable) PUMP&1NEL1 ENVIRONMENTAL HEALTH PERMIT r�11 COMPLETE IN TRIPLICATE .r� WATER QUALITY 04-3— (so-0/ Application is hereby made to'the San Joaquintocal Health Distnctfora pefmitto'cb'ristruct and/or install thework 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 Ave'oe- City/Towne ` Owner's Name Phon Address X City Contractor's Name Ni y�wLicense#3/?/_3 Business Phone 3 — 1/. 7 8- Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �Xl — TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 00 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ BUMP INSTALLATIONO, PUMP REPAIR❑ REPLACEMENT❑ I DISTANCE TO NEAREST: Septic Tank ,e Sewer Lines lie Pit Privy 044 d Z, Sewage Disposal Field Cesspool/Seepage Pita Other � � Property Line,/ Private Domestic Well QAVV Public Domestic WeIIN INTENDED USE .TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation�f ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing r� IT DOMESTIC/PUBLIC ❑ DRIVEN ./Gauge of,Casing lIRRIGATION ❑ GRAVEL PACK r- y Depth of Grout Seal w❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL v Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of'Pump` H.P. PUMP REPLACEMENT: ❑ State Work Done r PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth l 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 certifiespthe following:"i certify that in the performance of the work for which this.permit is issued, l 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 for which this per.niit is issued, 1 shall employ persons subject to workman's compensation laws of California." 1'wi call for a Grou Ins ection prior to grouting and a final inspection. Signed X Q :� V Title: Dale. (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY T _14' PHASE I ` Application Accepted B Date t Additional Comments- Kase 11 Grout Inspection t se II Final !ns ection I Inspection By Date F Inspection By ate i1 ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED g DATE DATE REMITTED AMOUNT L FEE LESS PRORATION - PLUS PENALTY OTHER OTHER s I - Received by Date Receipt No Permit No. issuance Date Mailed Delivered I, APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICE5 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA-952131