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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �FORROFFICE use: APPLICATION - (For Non-Transferable, Revocable, Suspendable) I PUMP&WELL `> t 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 cLan Jo uin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address Yi6 City/Town r_e 7-rri Owner's Name kt?S Phone i Address :3,6 o -Z— ��i zpere4.-n 0 City TILV e.,ff/i` I` Contractor's Name , tvteL_ License # Business Phone_ Contractor's Address emergency Phone 14Cfee Is Certificate of Workman's Compensation Insuran on File With SJLHD? . Yesy No d TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION C PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank -Z Sewer Lines Pit Privy Sewage Disposal Fief�X 7� Cessp000l/S�epage Pit Other Property Line� Private Domestic Well M Public Domestic Well W INTENDED USE TYPE.OF WELL N ❑ 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 ;r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i ❑ DISPOSAL ❑ OTHER Other Information © GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor W L 4 ple1 Type of Pump Ta 6 At 1° H.P. i • PUMP REPLACEMENT: +0 State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: :Well Diameter Approximate Depth Describe Material and Procedure -1 i --RI 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. a Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich 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 forwhich this j permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call f r a Grout Inspection prior to grouting and a final inspects Signed X # TIlIe: Date: Cry (Draw Plot Plan on Reverse Side) ! jOR DF PART ENT USE ONLY PHASE I Application Accepted By Date Additional Comments: f ' Phase II Grout Inspection Phase III Final Insaction i Inspection By. Date Inspection By� � ��.�_ Date 7— 8a Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 'I REMIT i BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED .� AMOUNT FEE LESS I 1 PRORATION PLUS � f PENALTY 117 (J OTHER OTHER �. Received by Date - ..F. Receipt No. Permit No. 6suanct Date - Mailed Delivered ..] -� PPLICANT—RETURN.AIL COPIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,:1601 E.HAZELTON AVE.,li 2009 STOCKTON,CA 95201- .. .. .� .