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Applications_ Will Be.Processed When Submitted Properly Completed.Be Sure To Sign The Application. FOR OFFI( E USE: APPLICATION 4 'gyp (For Non-Transferable,Revocable,Suspendable) eff PUMP&WELL ENVIRONMENTALI HEALTH PERMIT �. (COMPLETE IN TRIPLICATE) WATER QUALITY 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 i made in compliance with San JoaquinCounty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address /�a � ''fir 101,60 Al Alf401 City/Town Owner's Name Q a-V 1 /�" $3 ...�^--^° . Phone AddressCity Contractor's Name db: ' License#193 Business Phone,CL Contractor's Address D ID SL Emergency Phone Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes X No F TYPE OF WORK{OHECK}: NEW WELL❑t DEEPEN ❑RECONDITION❑ DESTRUCTION❑ - WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER 11PUMP INSTALLATION 12 PUMP REPAIR© REPLACEMENT❑ k 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 1 ❑ INDUSTRIAL -❑•CABLE TOOL Dia. of Well Excavation 13 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC / 11 DRIVEN Gauge of Casing ® IRRIGATION—St'etlk Wo-+"" ❑ GRAVEL PACK Depth of Grout Seal - I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑'OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By PUMP INSTALLATION: Contractor 3 Type of Pump s'e H.P. PUMP REPLACEMENT: ❑ State Work Done- PUMP 9 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. 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." Contractor's hiring or sub-contracting signature certifies the following:"l 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." Y I wiwill all fora Grout Inspec ion ri to gr ting and final inspection. Signed 1C� tie: Date: (Draw Plo Ian on Reverse Side) ' j -•� - r FOR DEPARTMENT USE vONLY _-.,.-- PHASE " = Application Accepted y - .�� 1 } Date Additional Comment _ Phase II Grout Inspection as Final inspectioVa ,.,,ed � Date Inspection By Date i Inspection By s Fee Is Due: ❑ ANNUALLY ❑ PER UNiTRXPL ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i By July 31 r REMIT BASE BILLING REMITTANCE $ AMOUNT DUE CHECKED yDATE DATE REMITTED f AMOUNT FEE LESSPRORATIONPLUS PENALTY OTHER _ OTHER �l , Y I .. 7 Reived by Date Receipt No. Permit No. Suance ate Mailed. Delivered ec APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER#AtT1SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=20119 STOCKTON,CA 95201 ;