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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. f FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL COMPLETE IN TRIPLICATE). WATER QUALITY 330-1/ Application is hereby made to theSan Joaquin Local Health Districtfafa permit to construct and/or install the work herein described.This application is h made in compliance with San Joaquin County Ordinance No. 18P2 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address r gW4 0ejai"w C";T, hL*u as4 /4' ZZCity/Town Owner's Name . Phone Address S City t Contractor's Name 154 — License#�3 �+3�Business Phone Z Contractor's Address – Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�F No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONO O WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® REPLACEMENT❑ () DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Y Sewage Disposal Field F_ 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 r` ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing " 1Z IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION +� _ ❑ ROTARY T I ype of Grout ❑ DISPOSAL ❑ OTHER Other Information I ❑ GEOPHYSICAL Surface Seal Installed y: f PUMP INSTALLATION: Contractor F Type of Pump H.P. 111�1416 a PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ® State Work Done_ �ll�_I� �• �' e.0 4N 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." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this i permit is issued, I shall employ persons subject to workman's compensation laws of California." Iill call fpr a Grout Inspectio rill to routi and a final inspection. a Signed IerfCJ bate: ac_ (Draw Plot an on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By O Date Additional Comments: r Phase 11 Grout Inspection Phase III Final Inspection r- Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE !!! LESS 1 411�0 PRORATION PLUS PENALTY OTHER ( OTHER Received by Date Receipt No. Permit No. Issuance Date - Mailed Dedvered' ... APPLICANT—RETURN-AUL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 r I.