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i ApplicationsWill Be Processed When Submitted Properly Completed. Be' Sure To Sign The Application,— FSR OFFICE USE: APPLICATION r (For Non-Transferable, Revocable,Suspendabfe) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL {COMPLETE IN TRIPLICATE) WATER QUALITY 1 Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address City/Town _.�244P67 C/g— Owner's Name--A44`— Phone 334-- �7St!o Address /S /W City r '7O Contractor's Name I ,� License#3 �Q�o2Business Phone Contractor's Address F/f/TS Emergency Phone f Is Certificate of Workman's Compensation Insurance on File With SJ HD? Yes No TYPE OF' ORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONS DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLAC MENT❑ i DISTANCE TO NEAREST: Septic Tank ! Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other _ ! Property Line/ . Private Domestic Well �Public Domestic Well INTE DED USE TYPE OF WELL ❑ INDUSTRIAL ' IIdo A CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing E�frST.fl�la/, `per ❑ DOMESTIC/PUBLIC El DRIVEN IRRIGATION 11 GRAVEL of Casing �p GRAVEL PACK Depth of Grout Seal , d7rC.e_ ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout AA0-+-•--tom ❑ DISPOSAL AL 1-1OTHER GEOPOther Information ❑ YSICAL I. ,face Seal Iristalled By: !ST/�flG PUMP INSTALLATION: Contractor yI� Type of Pump H.P. 0/6PUMP REPLACEMENT. ❑ State Work Done PUMP REPAIR: ;1 ❑ State Work Done i DESTRUC rjON OF'WELL: Well Diameter Approximate Depth i! 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. ome owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit s 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:1 certify that in the performance of the work forwhich this ermit is issued, I shall employ persons subject to workman's compensation laws of California." will all fora rut nspection prior to grouting and a final inspection. Signed X Title. _ ® � -Date: (Draw Plot Plan on Reverse Side) FOR DtPARTMENT USE ONLY PHASE I Application Accepted Additional Comments: �a Oh ah Date Phase if rut I pection a III f=inal Inspection I spection By Date. Inspection By p to Fee I El ANNUALLY 13 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ eDceived By July 31 BASEEXPLANATION BILLING REMITTANCE $ REMIT r ' DATE DATE REMITTED AMOUNT DUE CHECKED FEE AMOUNT ��,� LESS PROR TION 1 e PLUS PENAL.. OTHER I OTHER J Received by Date Receipt No. Permit No. ssuance Date. Mailed APPL CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Delivered , �_ 1641 E..HAZELTQN AVE.,P.O.Box 2009 STOCKTON,-CA-95201.