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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, Suspend able) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) ( WATER QUALITY L y x- Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install thework,h�.terein described.This application is 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 2_?'� — CkA'I k 2. �J _� City/Town Owner's Name .:-f1 :. `u o; Phone ,`,'f> Address City �( Contractor's Name O License#�� B sEiness Phoney D� Contractor's AddressJOL( Emergency h ne llk� N . ii. Is Certificate of Workman's Com_ pensat n Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIO ❑ w DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION 11 PUMP REPAIR❑ Q REPLACEMENT 111 !" DISTANCE TO NEAREST: Septic Tank Sewer Lines r Pit Privy 1. Sewage Disposal Field Cesspool/Seepage Pit Other ,r Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL - '` —_ C],CABLE TOOL - 'Dia. of Well Excavation w, - ❑ DOMESTIC/PRIVATE i ❑ DRILLED Dia. of Well Casing .DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of-Grout.Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout t ❑ DISPOSAL j ❑ OTHER Other Info�matibn ❑ GEOPHYSICAL I Surface.Seal Installed By: r PUMP INSTALLATION: Contractor Type of Pump } H.P. PUMP REPLACEMENT:' ❑ State Work Done '-t PUMP REPAIR: State Work Done t . VYIJ� DESTRUCTION OF WELL: Well Diarneter='__ fi '� Approximate Depth Describe Material and Procedure_ - f. I s I hereby certify that I have prepared this application and that the work will be done n'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 a ;:. 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-dontracting signature certifies the following."I certify that in the performance of the work for which this permit is ' ued, I shall employ persons subject to workman's compensation laws of California." I wi all for a Grout I pction prior to grou Ing and a final inspection. !Signed Y, -I'A19 Title: Date:..... ' (Draw Plat Plan on Reverse Side) P� 4' FOR DEPARTMENT USE ONLY #PHASE I Application Accepted By. Date r Additional Comments- .Phase II'Grout Inspection e,,IWFin nspection Inspection By E In �N Date Inspection By -Date Fee IS Due: ❑ ANNUALLY ❑ PER UNIT '❑ PER SITE ❑ EACH' ❑ January 1-&ReceiQd'By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT - EXPLANATION - AMOUNT DUE CHECKED � DATE DATE EMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY s ' OTHER g� } M 1 - } i OTHER I■ft{ Received by ..Date y� - - Receipt No. - Permit No. - ssuanc Dale• Mailed Delivered - - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ !V 1