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` - Applications.Will Be Processed When Submitted Properly Completed. Be Sure To Sign S pp ca Ion. roR oFslcE USE: APPLICATION SEP 24 1981 (For Non-Transferable, Revocable;Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT SAS; JOr:QUIN LOCAL WATER QUALITY .- HEALTH DISTRICT (COMPLETE IN TRIPLICATE) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1662 and the.rules and regulations of the San Joaquin Local Health District. City/Town . Exact Site Address - Phone �✓��` I Owner's Name J City l+ Address Contractor's Name License#'gillBusiness Phone Contractor's Address s Emergency Phone ' / 1No 1 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes✓ ^5 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑• DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ O� DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic W6II Public Domestic Well INT DED USE TYPE OF WELL INDUST IAL ❑ CABLE TOOL Dia. of Well Excavation INDUST /PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTI /PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGAT N ❑ GRAVEL PACK Depth of Grout Seal F ❑ CATH IC PROTECTION ❑ ROTARY Type of Grout f ❑ DISP SAL ❑ OTHER Other Information ❑ OPHYSICAL i Surface Seal Installed By: P INSTALLATION: Contractor J H.P. Type of Pump PUMP REPLACEMENT: El SS e Work Done ` PUMP REPAIR: L'�"State Work Done I DESTRUCTION OF WELL: Well Diameter. Approximate Depth =� k Describe Material and Procedure � I r 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:"I 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." L Contractor's hiring or sub-contracting signature certifiesthe following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subjec to'wor man's compensation laws of California." for a Grout Ins esti rior tog ting a final inspection. Signed X Title: Date: (Draw Plot Plan on Reverse Side) AOR DEPARTMENT USE ONLY PHASE I C-1 Date i Application Accepted By Additional Comments: P ase II Grout Inspection h 11�Finl nspection f� `1qQ? { Inspection By Date Inspection By Date ( 1"[ Fee is Due: 171 ANNUALLY ❑ PER UNIT • ❑ PER SITE El EACH'" ❑ January 1 &Received By"January 31 , ElJuly 1 &ReceiveREMITd By uly 31 BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT ©0 FEE` } LESS } PRORATION - PLUS PENALTY j OTHER OTHER r - .s Receipt No. Permit No. I suance Date Mailed- Delivered Received by pate APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 951