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l Applications Will Be Processed When SubmittedProperlyCompleted. BeSureTosign theRppncauon FOR OFFICE USE: APPLICATION i (For_ Non-Transferable, Revocable,Suspendable) PUMP&WELL ; ENVIRONMENTAL HEALTH PERMIT WATER QUALITY O (COMPLETE IN TRIPLICATE) II � I Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or install the work herein described.This application,is $ made in compliance with San Joaquin Count Ordinance.No. 1862 and the rules and regulations of the San Joaquin Local Health District. p Q I to �� ,E City/Town Exact Site Address 1 Ave Owner's Name ry i1 �� Phone Addresses-I ! tY] A `P2 t ° ' , City Contractor's Name License# 7 Business Phone 6r-e352 �FileZZ�hSJLHD? Emer enc Phone Contractor's Address g yIs Certificate of Workman's Compensation Ins rance on Yes G.— No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ( WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP-REPAIRGW-- [ REPLACEMENTS DISTANCE TO NEAREST: Septic Tank / ct-� Sewer Lines A-Cal--rPit Privy I' z .,. Seage-Disposal Field Cesspool/Seepage Pit Other Property Line YON I Private Domestic Well Public Domestic Well INTENDED USEi i TYPE OF WELL ❑ INDUSTRIAL i1 I El TYPE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE q ❑ DRILLED Dia. of Well Casing El DOMESTIC/PUBLIC I� � ❑ DRIVEN Gauge of Casing 18 IRRIGATION it �; 11 GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION " ;; ❑ ROTARY Type of Grout - ❑ DISPOSAL r ❑ OTHER Other Information 13 CAL Surface Seal Installed By: PU P INSTALLATION: Contractor AJ f ff.e !� it Type of Pump H.P. } PUMP REPLACEMENT: I` ;: ❑ State Work Done G �` 1 PUMP REPAIR: ❑ State Work Done t DESTRUCTION OF WELL: Well Diameter Approximate Depth t !i Describe Material and Procedure r 1 1 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 for which this permit is issued, I shall not employ�lany 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 - permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout ectlion prior to grouting and a final inspec'on. Signed X Title: Dater Ij (Draw Plot Plan on everse Side) I I rx FOR DEPARTMENT USE ONLY PHASE I IL Application Accepted By- ° - - • Date' Additional Comments: ! Phase 11 Grout Inspection B Inspection Ins ' Phas nal Inspection D Inspection By ' �' Date P y ate Fee IS Due: ❑ ANNUALLY 11 El "PER UNIT PER SITE ❑ EACH ❑ January 1 8 Received 8y January 31 ❑ July 1 8 Received July 31 I i REMIT '1 EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE II IY DATE DATE REMITTED AMOUNT FEELESS k PRORATION I tNo. t PWSPENALTYOT4-IEROTHERReceived by Date .� Receipt No. Permit Mailed Delivered.APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES E",P.O.Box 009 STOCKTON,CA 95201 !