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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: 11 1 APPLICATION CCty�J]E�.*� (For Non-Transferable;Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) S4.WE� 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 rA #A r Q-4 "✓ 14.4 cad—S_F', T-e City/Town Owner's Name �.� _ r / f ne— Phone-------�- Address —_ 0 City.. Contractor's Name Jeya1 u,r . License# GJ37A%r- Business Phone_ -/ Contractor's Address `�' +� Emergency Phone Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION L 1 DESTRUCTION❑ O� WELL CHLORINATION ❑ WELL ABANDONMEWT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO IJEARESI: Septic Tank Sewer lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other _ Property Line Private Domestic Well Public Domestic Well IN-ibED USE TYPE OF WELL - '"�C1 IND STRIAL� ❑ 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 l ❑ DISPOSAL ❑ OTHER Other Information _❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALATIONi Contractor Type of Pump .✓J� " H.P. PUMP REPT ACEMENT: ❑ State Work Done. m PUMP REPAIR: ® State Work Done CGILAIdS, 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- 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"Itub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shalYemploy persons sub'e4 to workman's compensation laws of California." 1 w-I call for a Grout Inspectio lo grout! and inal inspection, t Signed Xm�/ rile: T/� __ Date: 6 I (Draw Plot an on Reverse Side) kFOR DEPARTMENT USE ONLY PHASE I Application Accepted By�� -- 1 Date_6> L Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By�&, � Date IIS k Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 37 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE /9— LESS LESS PRORATION PLUS PENALTY OTHER t - OTHER Ll Received by Date - _ Receipt No. e 'it iNo, Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-E.HAIELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201