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ApplicationsWill BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (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 Q City/Town Owner's Name /JAn&lv K Phone Address ``llf, City Contractor's Name 4& �� . �C license# S Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_9 No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR.. REPLACEMENT❑ 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 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump_71J4441-41,5 H.P,_ I17 PUMP REPLACEMENT: ❑ State Work Dane 11 PUMP REPAIR: X,State Work Done 04J Cf DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure /4/ ?_Z4—V 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. : Home owner 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." Contras is hiring sub-contracting signature certifies the following."I certify that in the performance of the work for which this perm s issued, I all employ persons subject to workman's compensation laws of California." I Inspection prior to grouting and a final inspection. t �` Sig< a �� Title. Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date/'6�a Additional Comments: 104 .Phase 11 Grout Inspection Phase III Final inspection Inspection By_ Date Inspection By Date Z�s Fee Is Due: ❑ ANNUALLY ❑ PER UN11 ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 S Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 77 LESS PRORATION L� PLUS PENALTY OTHER OTHER Received by [late Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ - _:-'1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201