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.. Applications Will Be Processed When Submitted Properly Complete a ure o Ign ICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT � WATER QUALITY (COMPLETE IN TRIPLICATE) 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 5 n Joaquin County Ordinance No. 1862 and the rules and��ul�tions of the San Joaquin Local Health District. l t1 �Gtr45� A '�s City/Town Exact Site Address t a � it ; Owner's Name Phone ` City License# /��7�Business Phone 7� Address Contractor's Name �y Contractor's Address !A0 �^' Emergency Phone - Is Certificate of Workman's Compensation nsurance on File Wi SJLHO? Yes,K— No n TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑❑ {OTHERCON❑DITI P❑P DESTRUCTINSTALLATIOO❑❑ PUMP REPAIR❑ 3 WELL CHLORINATION 13 WELL ABANDONMENT REPLACEMENT❑ J Pit Privy DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal . ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 3 ❑ DISPOSAL ❑ OTHER Other Information th El GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor H.P. Type of Pump PUMP REPLACEMENT: ❑ State Work Done 1 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, l shall not employ any person in such manner as to become subject to workman's compensation laws of Californias Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work tor which this permit is issued, I shall employ persons subject to workman's compensdtion laws of California." } I will all for a Grout Inspection pri r o rou`tin d nal Inspection. life: Date: � I Signed X ( raw Plot an on Reverse Side) FOR EPARTME USE ONLY PHASE I pato Application Accepted By Additional Comments: ,,yam t Phase II Gro- inspection /% P� Finatlnspectinn Inspection By Date inspection By v" to Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 July 1 &Recei.v d By REMf t EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECK BASE DATE DATE REMITT AM U f �} FEE LESS PRORATION k PLUS PENALTY OTHER OTHER issuance D e Mailed Delivered i-Received by Date Receipt No. Permit No. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 05201