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Applications Will Be Processed WhenSubmittedProperly L;omplel:e � as�e�uwyr�•anry •��tTTi l_r�a FOR OFFICE USE: r APPLICATION n L� (For Non-Transferable, Revocable, Susp a le)OEC 3 198U PUMP&WELL �„ E ENVIRONMENTAL HEALTH PERMIT �I , l f. WATER QUALITY SAN JOA, U f N LOCM. i4ilk (COMPLETE IN TRIPLICATE) � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ori r I rlbed.Thisapplication is made in compliance with San Joaquin Count Ordinanc No. 18 2 an the rules and regulations of the San a uin Lo al eaith Di rict. Exact Site Address — City/Town G Owner's Name e-iD Phone Address City e - - r Contractor's Name �.+�....,1J� License#��Business Phone_ Contractor's Address A S1 ` Emergency Phone �Sz.- Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes +01- No `xh TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ L' WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ Q DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other J Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Lr. 11 IRRIGATION E3 GRAVELPACK Depth of Grout Seal f1 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHERInformation 11GEOPHYSICAL S rf a Seal Installed By: PUMP INSTALLATION: Contractor L. Type of Pump H.P. PUMP REPLACEMENT: ,❑1 State Work Done x Ile PUMP REPAIR: L�State Work Dane DESTRUCTION OF WELL: Well Diameter h AQproximat Dept Describe Arterial and Proce pre Q �' 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. Ho r licensed agent's signal certifies the following:"I certify that in the performance of the work for which this permit i ssued, I sha not employ any Pers n in such er as to become subject to workman's compensation laws of California." Contractor's hiri g or sub-conlractin si n t certifi s the follow' certify that in the performance of the work for which this permit i issue I hall emplo pens s ct to rkman's ompensation laws of California." I 'I c a G ut Inspecti nd a final spection .. �.. Date: Signed (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By Date3a - Additional Comments: Phase 11 Grout Inspection III Fin I Inspection Inspection By n Date Inspection By Date [/ 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 LESS - PRORATION PLUS PENALTY OTHER OTHER rr �J Received by Date Receipt No. - .Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520