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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Fo _ USE: APPLICATION (For Non-Transferable, Revocable,Suspendablej . L. PUMP&WELL ENVIRONMENTAL 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 is ` made in compliance with San Joaquin County Ordinance No. 1862 and the rule nd regulations of the San Joaquin Local Health District. Exact Site Address �l City/Town 77� Owner's Name Phone C Address RAXCityyJ Contractor's Name r b11 License#3 g/ Business Phone -� ��7h=.7 v Contractor's Address 4e , ,-AL- Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ P WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRW REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy t Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well 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 a ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seals ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i, ❑ DISPOSAL ❑ OTHER Other Information f ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor l Type of Pump H.P. i PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: State Work Done DESTRUCTION OF WELL: Well-Diameter Approximate Depth Describe Material and Procedure--- �+ 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.; i Home owner 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 wor.kman'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 jermit is issued, I shall employ Permit p y persons subject to workman`s.compensatio•n`laws of California." -- j I wil � 11 for a Grout Inspection priUr tt,9 grouting and a final inspection. - ��) �d Signed X s L `Title ,�: _ ' Date: " .— n (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By Date 1-:5 Additional Comments: Phase 11 Grout Inspection h*e III Fin Inspection I Inspection By Date Inspection By `Date 3'-/D_e/ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT _❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ` BILLING REMITTANCE $ REMIT i BASE EXPLANATION DATE -DATE REMITTED - AMOUNT DUE CHECKED AMOUNT FEE J/C� f LESS: II PRORATION PLUS PENALTY - OTHER OTHER l Received by, - �Date Receipt No. Permit No . - Issuance Date Mailed - Delivered- ,.._ - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERMIT/SERVICES - 1601 E:,HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA,95261 I