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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR ZFFICE USE: APPLWATION (For Non-Transierable, 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 ,L City/Town__ ��4// Owner's Name Z [7At Phone _/ Z /Q/ Address S City Contractor's Name License#3I 1/S/ Business Phone / Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes-� No I� TYPE OF WORK (CHECK): " DEEPEN RECONDITION E DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ 1 DISTANCE TO NEAREST: Septic Tank f Sewer Lines Pit Privy Sewage Disposal Field /00 J{ Cesspool/Seepage Pit ��- Other Property Line/0't Private Domestic Well s50(Public Domestic Well INTENDED USE TYPE OF WELL r� INDUSTRIAL JK CABLE TOOL Dia, of Well Excavation X DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing er ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 11 M�+ ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ---�- ❑ GEOPHYSICAL Surface Seal Installed By: 49gcJdyXP PUMP INSTALLATION: Contractor Type of Pump H p PUMP REPLACEMENT: ❑ State Work Done 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. 1 Homeowner 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 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." I will call for a Gro t Insp on i to grouting and a final inspection. - t Signed X Title: Date: (Draw Plot Plan on Reverse ide) PHASE I F R DEPARTMENT USE ONLY Application Accepted By ' �^^ Date Additional Comments: Phase Il Grout Inspection h II al Inspection 42- Fee Inspection By Date Inspection By Date � 3�6 Z Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Re ed By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT - FEE LESS PRORATION PLUS PENALTY r7 OTHER .01 OTHER Received by Dale Receipt No Permit No. � ssua2ce Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 60i E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201