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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Fli OFFICE USE: APPLICATION. t, t i (For Non-Transferable, Revocable,Suspend ible) ENVIRONMENTAL HEALTH PERMIT PUMP WELL (COMPLETE IRI TRIPXATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is made in compliance with San oa�uln ounty�rdina No`. 1,862 a d the rule a//��r,egul tions of the S ,J�aquin Local Health V'stric Exact Site Address �� ILL'�f"_( i -6�1J'1 L[, Q /y`G[rS ty/To\A �L/�_ Owner's Name �r / ./( Phone 7 -&7C 7 Address City Q Contractor's Name Alelm tii /'r� License# 60,90,M Business Ph ne�_J S-`tli0_9�5__ Contractor's Address Emergency Phone �.53Z -'V ?7/ Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL Lel DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ t f� DISTANCE TO NEAREST: Septic Tank �0Sewer Lines Pit Privy Sewage Disposal Field ��© � Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL LEII, USTRIAL ❑ CABLE TOOL Dia. of Well Excavation /DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing on 11DOMESTIC/PUBLIC �❑,, D EN Gauge of Casing /idr L4 Q a"-,) E] IRRIGATION rC GGRRAVEL PACK Depth of Grout Seal 1529 U ❑ CATHODIC PROTECTION 'ROTARY Type of Grout Bi7� ❑ DISPOSAL ❑ OTHER Other Information li ❑ GEOPHYSICAL Surface Seal Installed By: 0 PUMP INSTALLATION: Contractor _1 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit C 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 WiV call for a Grout insp n prior to grouting and a final inspection. Signed X ^ Title: Date: 7`•� 1,176 (Uralif Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Z Date �U Additional Comments: Phase II Gr ut Ins eclJon APhase III Final Inspection Inspection By at _ Inspection By bate -2 11 Fee I5 Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 $,Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS L PRORATION PLUS PENALTY- OTHER OTHER 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.Boy 2009 STOCKTON,CA 9520 .