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r Applications Will Be Processed When Submitted Property Compietea. ne sure is sl e�YP��cn«v,•• t i S t FOR OFFICE USE: APPLICATION p 1 (For Non-Transferable, Revocable,Suspendable) APR 2 ��k PUMP&WELL ENVIRONMENTAL HEALTH PERMIT olr t� LOCAL ,� R�(tUALITY SAN .1 L", �� TR(CT (COMPLETE IN TRIPLICATE) Z�ZZ[�/, .�'� n'Gc(SO'� T_J.t Z�cl"�SO�dZ HEALTH `S Application is hereby made to the Sari JoaquiF Local Healff District fora permit to construct and/or install the work herein described,This application is made in compliance with San Joaq in County Ordinance No.1862 and the rules and regulations of the San quip Local Health District, Exact Site Address City/Town --rte Phone Owner's Name Address City Contractor's Name W �P` License# Z f Z Business Phone t Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Alnurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELDEEPEN ❑ RECONDITION❑ DESTRUCTION❑❑ ❑ i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR O REPLACEMENT❑ I DISTANCE TO NEAREST: Septic Tank Sewer Lines _( Pit Privy ^^ ; Sewage Disposal Field Cesspool/Seypage Pit Other t Property Line Private Domestic Well Z C Public Domestic Well ^-•-� INTENDER USE TYPE OF WELL �f 4`❑�NDUSTRIAL C1 CABLE TOOL Dia. of Well Excavation J�pOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing [[[❑ DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing © IRRIGATIONrEol RAVEL PACK Depth of Grout Seal ej El CATHODIC PROTECTION OTARY Type of Grout 11 DISPOSAL THER Other Information .i ^' ' ❑ GEOPHYSICAL surface Seal Installed By' ill N PUMP INSTALLATION: Contractor t Type of Pump H.P. N PUMP REPLACEMENT: ❑ State Work Done ; Ny 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 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 for which this permit i 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 persons subject to workman's compensation laws of California." [4i _r I will c i for a Grout spection prior togroutingand a final inspection. Signed X Title: �. Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE IaQ�� f Application Accepted By t i Date t 4 M Additional Comments: Phase II Grout Inspection �f P se in Inspection ByGAN iv!) Date / —49— SV Inspectio f Fee Is Due: ❑ ANNUALLY` ❑ PER UNIT –1PER SITE El EAC H J uary 1 &Received By January 31 ❑ July l &Received By July 31 REMIT RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT t FEE LESS , ! PRORATION PLUS I PENALTY OTHER OTHER Received by Date Receipt No. - Permit No. Issuance Date MailedDelivered APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMITISERV10ES 5661 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 t: