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Applications Will Be Processed When Submitted ompleted. Be Sure To Sign The Application. FOR OFFICE USE: APPLtc;pr l WN grey„ Off. (For Non-Transferable, Revocable, Suspendable) PUMP&WALL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made tolthe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin Coun�tyOrdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address At 49, R+e City/Town C[` I" Phone ��^ :Z- ec " Owner's NFa�me 1 Address e a+y d City Contractor's Name L v L ? icense 4waf Business Phone Contractor's Address Emergency Phone - Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes No TYPE OF WORK (CHECK):it NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL- CHLORINATJON ❑ if WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION El PUMP REPAIR❑ REPLACEMENT — DISTANCE TO NEAREST: Septic Tank , Sewer Lines Pit Privy F i Sewage Disposal Fiel 7 % Cesspool/Seepage Pit Other Property Line Uo Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL r11 INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation 1 #$DOMESTIC/:PR:IVATE ❑ DRILLED Dia. of Well Casing Li DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL_ PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout + ❑ DISPOSAL it C1 OTHER - Other Information s ❑ GEOPHYSICAL k S_urface Seal Installed a y: f C` PUMP INSTALLATION: Contractor UA-T f% nee111111111111,01_ - I Type of Pump P --, �•� t .P. PUMP REPLACEMENT: -State Work Done PUMP REPAIR: I. ❑ State Work Done DESTRUCTION OF WELL:�• Well Diameter Approximate Depth Describe Material and Procedure I hereby certify ithat 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." ' Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this i ? permit is issued)I shall employ persons subject to workman's compensation laws of California." 1 I will all for a Grout nspecti rior to grouting and a final inspe II "� Signed X I Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPAR MENT USE ONLY PHASE I I� F Application Accepted! By Date i Additional Comments: Phase 11 Grout Inspection Ph III at Inspection Inspection By I�_ Date Inspection By ate i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT _._❑ PER SITE ❑ EACH- ❑ January 1 &Received By January-31 ❑ July 1 &Received By July 31 ` REMIT II.BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED PP DATE DATE REMITTED AMOUNT FEE LESS Ii �- PRORATION PLUS ' II PENALTY I� OTHERr OT•HEW 1 Received by I` Date --. - Receipt No, .Permit Na. Issuance Date Mailed Delivered fl APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201