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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Y FOR OFFICE USE. APPLICATION (For Non-Transferable, Revocable;Suspendable) PUMP&WELL i ENVIRONMENTAL HALTH PERMIT I (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 S Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address City/Town Owner's Name Phone Address '" City Contractor's Name__ 4, L!6ense#c26 bq6 Business Phone_ Contractor's Address 1zEmergency Phone - Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L11__ No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION© DESTRUCTION❑ - WELL_CHLORINATION ❑ WELL.ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ t REPLACEMENT❑ �,.. DISTANCE TO NEAREST: Septic Tank Sewer Lines - Pit Privy Sewage Disposal Field Cesspool/Seepage Pit '+Other •. •i - . , Property Line Private bomestic Well 1 � `�, . Public Dornes(ic Well,A INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ••-- •------ j•-❑-CABL-E'-TpOL--^_--•------Dia:•of-Well Excavation— El DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing f ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION i ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL '. s j❑ OTHER `Other Information © GEOPHYSICAL _ y ' r{ Surface Seal Installed ByJ PUMP INSTALLATION: ., -Contractor Q "Type of Pump t H.P. PUMP REPLACEMENT: ❑j State Work Done PUMP REPAIR: I ❑',State Work Do D DESTRUCTION OF WELL: t— Well Diameter ' Approximate Depth Descibe Mat riot and Proced re I � I hereby certify that I have prep ed this application an 4hat the work will be done in accordance with S Joaquin County ordinanbes, state laws, and rules and regulations of the San Joaquin Local Health District. I 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 suchManner-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 i's issued, I shall employ persons subject to workman's compensation laws of California." Ir z I will call for a Grout Inspection prior to grouting and a tinel inspection: Signed X Title: 4��. Z7,2e.6, .enn., _ - Date: (Draw Plot Plan on Reverse Side) L ;• ' FOR DEPARTMENT USEiONLY ; PHASE I i 97, Application Lcepted SBy Date Additional Comments: I Phase,ll Grout Inspection h III F• l Inspection Inspectibn By— .� Date Inspection By Date Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ January 1 &Received By;January 31 ❑ July 1 &Received By July 31 ' REMIT - BASE Xk EXPLANATION KILLING REMITTANCE $ AMOUNT DUE CHECKED I DATE DATE REMITTED AMOUNT ' 3 -- FEE } LESS . PRORATION �( PLUS PENALTY OTHER OTHER A Received 6yecei'p`YNo. Issuance'Date Mailed Delivered! APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 ;