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Applications Will Be Processed When Submitted Properly Completed. Be SureTosignTneAppllcailon y ' APPLICATION I "OFFICE USE: {For Non-Transferable, Revocable,Suspendable) � PUMP&WELL �� TU/PP I Ny RONMTTA HEATH PERMIT (COMPLETE IN TRIPLICATE TER.QUALITY Application is hereby matotheSanJoaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is —� made in compliance CP I-County Ordinance No. 1862 and the r nd regulations of the San Joaquin Local Health District. Exact Site Addres / �A City/Town Phone All Owner's Na e J �—/ lv Address City 70 CIC-7CA- Contractor's Nam y1J lopCl LI'Ca License Business Phone Contractor's Address/,(4 41 - &Acy Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK)': NEW WELL 11DEEPEN ❑ RECONDITION❑ DESTRUCTION ❑ r WELL CHLORINATION 11 WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION? , PUMP REPAIR❑ 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 ❑ IN STRIAL 13 CABLE TOOL _ Dia. of Well Excavation F DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN _, J) ::* }Gauge of Casing 11 IRRIGATION 13 GRAVEL PACK, r _Depth of Grout Seal r ❑ CATHODIC PROTECTION ❑ ROTARY 1 Type of Grout ❑ DISPOSAL ❑ OTHER --• Other Information 11 GEOPHYSICAL Surface Seal Irtalled By: PUMP INSTALLATION: Contracto L01 Type of Pump H P PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth a Describe Material and Procedure t 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 i 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 yforwthis perm Is Issued, I shall employ pers ns r bject t workman's compensation laws of California.— j i I l call for a Gro I ect'on or o�groufi and a sinal insp c o Signed X Title- D / (Draw Plot Plan on Reverse Side) i FOR DEPARTMENT USE ONLY PHASE I s^HSS (J/ Date Application Accepted By - — Additional Comments: 1 Phase II Grout Inspection Ph s III Fina Inspection -� Inspection By Date �'`� Inspection By Date I Z J Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 S 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 F PLUS PENALTY OTHER ¢ OTHER p - Permit No. 3—t0 - Issuance Date Mailed Delivered Received by Date. p -' Recei t No —RETURN ALL.0 PIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1 1 E.HAZELTON AYE.,P.O.Box 2009 sTOCKTON,CA 95201 el - _ r'! —`'q!