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Applications Will Be Processed When Submitted Properly FOR OFFICE usE: APPLICATION ; 4 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL Ilk ENVIRONMENTAL HEALTH PERMIT f WATER QUALITY (COMPLETE IN TRIPLICATE) Application is hereby made to the San Joaquin Local Health District fora permit construct and/or install the work herein described.This application Is - made in compliance with San Joaquin Go my Ordinanc No. 1862rand the rules and regulations of the 5antJoaquiL n ocai Health District. City/Town Exact Site Address 1' Phone Owner's Na e City Address �� License# Business Phone Contractor's Name Emergency Phone S Contractor's Address No ' Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION El WELL ABANDONMENT 11 OTHER 13PUMP INSTALLATION Z1— PUMP REPAIR 13 + i REPLACEMENT❑ r Pit Privy DISTANCE TO NEAREST: Septic Tank Sewer Lines Sewage Disposal Field Cesspool/Seepage Pit ,ltj7t7_) Other Property Line 162 Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL r r � CABLE TOOL .Dia. of Well Excavation 11 INDUSTRIAL es`/ r t �OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1 ❑ DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing 1:1 IRRIGATION C3 GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grouts ►� ❑ DISPOSAL OTHER Other Information Surface Seal Installed By: i ❑ GEOPHYSICAL -�S PUMP INSTALLATION: Contractor Type of Pump H.P. �- PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Dane 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. Y `[yam Home owner or licensed agent's signature certifies the following:"I certify that t the performance m the work for which this penial" is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." f 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." 1 I will call for a Grout Inspection prioE to grouting and a final inspection. Title: //�._/��°n Date: , Sighed X (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I ,Ql Date Application Accepted By 11i Additional Comments: F II Grout Inspection h e 111 Final Inspection Inspection By ✓ Date v Inspection By Date - Fee Is Dile. ❑ ANNUALLY ❑ PER.UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 .. REMIT BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT FEE f LESS PRORATION .r PLUS w. PENALTY - OTHER - - OTHER - 4. Recei t No. Permit No. - _ issuance Date Mailed Delivered ,.Received by l � Date p . •` —� — 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,C 0 , APPLICANT—RETURN,ALL COPIES TO:�. -ENVIRONMENTAL HEALTH PERMIT/SERVICES — �s 'R"