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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 WATER QUALITY . E (COMPLETE IN TRIPLICATE) ` *"� r 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. 18 nd the rules and regulations of the San Jd quin Local He,Ith District. w Exact Site Address 6 d �n� r' City/Town , I of ,��, �,� Phone r3 I Owner's Name + i SrA ; .. w City Ad d ress Contractor's Name *License#,.7Z 7II Business Phone__ �f��5 16 I.' Contractor's Address,�(J1?— ��'' i Emergency Phone Is Certificate of Workman's Compensation insurance on File_With SJLHD? Yes _ No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ "RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ t If DISTANCE TO NEAREST: Septic Tank f U :k Sewer Lines�40 "E Pit Privy I Sewage Disposal Flield ic Cesspool/Seepage Pit Other Property Line Private Domestic Well.Sy 'A Public Domestic Well INTENDED USE TYPE OF WELL L it ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation le+.DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC .❑ DRIVEN Gauge of Casing El IRRIGATION Depth of Grout Seal � - GRAVELPACK ❑ CATHODIC PROTECTION ',ROTARY Type of Grout _E E 4 ruy k ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL 4 Surface Seal Installed By: PUMP INSTALLATION: Contractor tl Type of Pu;p v H.P. PUMP REPLACEMENT: ❑ State Work Done State Work Dane PUMP REPAIR: ❑ 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:"1 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 became 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 em y persons subject to workman's compensation laws of California." 10 F I call for Grout Insp/' tion prior to grouting and a final inspection. Signed Title: Date: ^ r' (Draw Plot Plan on Rev se Side) FOR DEPARTMENT USE ONLY Q_ PHASE I ' pate Application Accepted By Additional Comments: hale II r4ti a 111 Final Inspection e, Inspection Bye' Inspection By Date �ry T r Fee IS DUB: ❑ ANNUALLY PER UNIT PER SITE © EACH ❑ January 1 &Received By January 31 0 July 1 &ReceivedREMITuIy 31 tllAEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER .' Received by Date � Receipt No, - Permit No. Issuance ate Mailed �_`_>Delivered - .. APPLICANT—RETURN ALL COPIES TTo: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 45201 :..