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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) 4 Ef�1'r-ONMENTAL HEALTH PERMIT PUMP&'WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is c made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 57 05 1 E1 r a ao City/Town Owner's Name Ao k-eit, Phone `" O Address r City__17�?22e, 211E AJ Contractor's NameZZ." v License++oEls7 !6 Business Phone Contractor's Address' -6- Aid Emergency Phone G Is Certificate of Workman's Compensation Insuran a on File With SJLHD?-r Yes L-- No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ C� WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Z— PUMP REPAIR REPLACEMENT❑ r ' DISTANCE TO NEAREST: Septic-Tank; _�_ 7 Sewer Lines 7:!rL' =� Pit Privy �1 -Sewage Disposal Field 77S f Cesspool/Seepage Pit Other 4' Property Line /h__ Private Domestic Well Public Domestic Well -INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE 13 DRILLED Dia. of Well Casing s ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout E ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor tirtI ai Type of Pump ru H. PUMP REPLACEMENT: El State Work Done 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit" rb ` is issued,.1-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 permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grou ns ection prior 1 grouting and a final inspection. Signed X Title: t A6hc Date: (Draw Plot Plan on Reverse Side) FOR.DEPARTMENT USE ONLY PHASEI �� Application Accepted By- ✓ — Date g �� r Additional Comments: r Phase 11 Grout Inspection ,., . .,, ,,.r,,n . hase III Final Inspection Inspection By Date Inspection By Date t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑'January 1 &Received By January 31 , ❑ July 1 8 Received-By July 31 REMIT' . BASE EXPLANATION BILLING _ R_EMI3TANCE $ AMOUNT DUE CHECKED I DATE„ 'DATE REMITTED ..AMOUNT T FEE LESS PRORATION PLUS - PENALTY - 1 OTHER ' OTHER 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.Boll 2009 -STOCKTON,CA 95201