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Appiicatlons Will 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 Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work.herein described.This application is made in compliance with San J aquin County�Ordinance No. 1862 and the rules and regulations of the San Joa uin Local Health District. ' Exact Site Address City/Townr „i Owner's Name Phone Address y City Contractor's Narr4e License# 04 Business Phone �fo— Contractor's Address �- 41e�Z, aC Emergency Phon>s/ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ,/ No �J TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 WELL CHLORINATIQN ❑ WELL ABANDONMENT 11 OTHER E] PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT' DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 1 f Sewage Disposal Field Cesspool/Seepage Pit Other V Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL T ❑ 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 ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: L PUMP INSTALLATION: Contractor Type of Pump R H.P. !' PUMP REPLACEMENT: u State Work Done24A&1F .r-kc e, ff Y>c� fG' fy �.► Y-f i PUMP REPAIR: ❑ State Work Done N 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." j 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." r I willcallfor a Grout Inspection prior to grouting and a final inspection. (y Signed X fiy� 117 .L5 JLe-t.u~ G.6?';A, Title: Date: Q ` V � '' — - (Draw Plot Flan on Reverse Side) — F RDE ARTMENT SE ONLY i. ' PHASEI / 0 Application Accepted By t Date J Additional Comments: Phase II Grout Inspection Aase III Final Inspection Inspection By Date Inspection By Date l` y' SF/- Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT j2rPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July:1 &•Received By Juiy 31 REMIT t B4LLING REMITTANCE $ '', f' BASE EXPLANAT ON AMOUNTDUE CHECKED I. DATE DATE REMITTED AMOUNT FEE r . LESS PRORATION PLUS r PENALTY OTHER -, OTHER ly 0_1(o!51 1`8 Jrip Received by - Date - Receipt No. Permit No. - Issuance Date Mailed Delivered - APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201