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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. 1R OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendabie) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT 1 (COMPLETE IN TRIPLICATE) WATER QUALITY ry 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 Jo q in County Ordi ce N 1882 and t rules and r ulations of the San Joaquin Local Health District" Exact Site Address C City/Tow(n �.� Owner's Name ` Phone Address - City Contractor's Name, License#/'7 7PZe) Business Phone -3. Contractor's Address EmergencyP one � � - Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes . No TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION'El DESTRUCTION❑ I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER-[] PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other i 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 -- f ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL © OTHER Other Information CA ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P- 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 certifythat 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." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." s I will tail for a Grout l9ppection prior to grouting and a final inspecn. Signed X Title: l/ Dater—/— (Draw ater/®(Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I u �D ,I Application Accepted By r y Date Additional Comments: II Phase II Grout inspection Phase III Final Inspection k Inspection By Date t Inspection By Date I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH, ❑ January 1 &Received January 31 ❑ July l &Received-By July 31 REMIT BILLING -., REMITTANCE $ - BASE ExPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION t PLUS PENALTY OTHER OTHER Received by .Date Receipt No: Permit No Issuance Date Mailed livered APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - ST.00KTON,CA 9