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ApplicationsWIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION ?` (For Non-Transferable, Revocable, Suspendable) -� PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY r Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is r made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. Exact Site Addres's , _I +<# City/Town Owner's Name 444411 � 5' 71// Phone Address City Contractor's Name License# 29_?�8usiness P-4ont 3 .� Contractor's Address r Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ d WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Jam/ Sewer Lines Pit Privy �`— Sewage Disposal Field Cesspool/Seepage Pit Other Property Line / Private Domestic Well_6� Public Domestic Well INTENDED USE _- —.TYPE OF WELL i ❑ INDUSTRIAL %CABLE TOOL Dia. of Well Excavation /,,Z T 152.7 t DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -9i11' ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing d j ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 0,42-Ate 7— ❑ DISPOSAL ❑ OTHER Other Information } ❑ GEOPHYSICAL rface Seal Installed By:_ B PUMP INSTALLATION: Contractor L77) Type of Pump �` H.P. � L\ PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ 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." a Contractors hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this f permit is issued, I shall employ persons subject to workman's compensation laws of California. I will II for a Grou Inspection irlor to routing and a final inspect/ilo�n,. Signed X Title: +� • Date: (Draw`Plot-Plan'on Reverse-Side) FOR DEPARTMENT USE ONLY PHASE I G Application Accepted By ► Date Additional Comments: e II Grout Inspection hasallI Inspectlon i Inspection By Date t Inspection By to Fee I5 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 1 &Received By.January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED AMOUNT FEE 6 LESS PHORATION PLUS -� PENALTY 1 OTHER OTHER - Received by Date Receipt No. Permit No. - Iss nce Date - Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201-