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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 (COMPLETE IN TRIPLICATE) WATER QUALITY 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'nty Ordinance NP 1862 a the rules and regulations of the San Jo quin Local Hea h District. Exact Site Address14'741)6_ IW49- l��f _. City/Town C _ Owner's Name Phone Address `�' City Contractor's Name k License# Business Phone l� Contractor's Address 7' Emergency Phone } Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4---' No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION P" PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field le Cesspool/geepage Pit �� Other Property Ling/W7* Private Domestic Well 77--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 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout © DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor r Type of Pump 41H.P. "'"► PUMP REPLACEMENT: ❑ State Work PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Weil-9ia �� Approximate Depth p� 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 ofthe workforwhich this permit 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." '!I c or a rout�Insp tion r' r 10 grou g and a flnai Inspection. � _ ,Sign d Title: GGY �y/G��► Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I K_ Application Accepted y +� Date . + Additional Commen Phase II Grout Inspection Phase til Final Inspection Inspection By Date Inspection By�YIA. Date G �} Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE S LESS PRORATION PLUS PENALTY OTHER OTHER [� i Received by Date Receipt No. Permit No I Issuande Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201