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Applications 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 madeto theSan Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is made in compliance with San Joaquin County dinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. , Exact Site Address� O - � 'y� City/Town _ r, Owner's Name $ Phone -� Address 00 r,:-!56 _ City Contractor's Name License# . ?a Business Phone r �� Contractor's Address "% Emergency Phone Is Certificate of Workman's Compensation yIns urance on File With SJLHD? Yes No } TYPE OF WORK (CHECK): NEW WELL: _ DEEPEN ❑ RECONDITION'0- DESTRUCTION❑ / fff WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 1:1 PUMP INSTALLATION 6: PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑- INPUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation OMESTIC/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: PUMP INSTALLATION: Contractor Q Type of Pump H.P. I PUMP REPLACEMENT: ❑ State Work Done X�011 PUMP REPAIR: ❑ State Work Done l" DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure �S I 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. m Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit c 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 C permit is issued, I shall employ persons subject to workman's compensation laws of California." fi I will call f a Grout Ins ction prior to grouting and a final inspection. f {o � Date: Signed _ � �/1-/ ... . _ Title: � 3 '"� ` f (Draw Plot Plan on Reverse-Side) r. FOR DEPARTMENT USE ONLY L - _ 01F .. f PHASE I I .Application Accepted By Date Additional Comments: I Phase II Grout Inspection Pha III final Inspection Inspection By Date _ Inspection By Date f� I Fell IS DUE: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH -❑ January 1 &'Recekved By January 31 ❑ July 1 E Received By July 31 l REMIT BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT FEE' �� _ f LESS r PRORATION PLUS Y PENALTY, OTHER ..T OTHER k Received by Date Receipt No. Permit No. -- issuance Date Mailed —Delivered t_ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 }