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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT r WATER QUALITY (COMPLETE IN TRIPLICATE) 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. 1 62 and the rules and regulations of the San Joaquin Local Health District. City/Town A e-- 'Cl. A Exact Site Addresl � � f r' Phone 7 �, " �C. Owner's Name City Address �� 1 _ Contractor's Name E'��rS'# License# u aZ3Business Phone `�� Contractor's AddrerEli "g"!�7V!Z,C_ Is,I� �" - L Emergency Phone F Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes dw— No116 TYPE OF WORK (CHECK): NEW WELL© DEEPEN ❑ RECONDITION ET' DESTRUCTION❑/ 0 WELL CHLORINATION ElWELL ABANDONMENT ❑ OTHER 13PUMP INSTALLATION ( PUMP REPAIR 13 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 2-'r BLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - �FtRIGATION ❑ 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 H P' PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 0 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:"l 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 GrolInspection prior to grouting and a final inspection. 1 Signed X _ , -� _ Title: � Date:CW (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I l /r rZy Date Application Accepted By Additional Comments: Phas III F'nal Inspection Phase 11 Grout Inspection Date Inspection By Date Inspection By Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE Fe e: i LESS PRORATION PLUS PENALTY OTHER OTHER m -� I Received by date —FIV15'eipl No. Permit No Issue ce Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ;