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: . Applications Will Be Processed When Submltted Properly Completed.q� APPLICAT. FOR OFFICE USE: i.e y Ida�bie PUMP&WELL (For Non-Yransferabl�f�vocadt ENV1R0NMENTA U EALTH PEP, WATEA� LITYSV? ��..��,,,,,,��- (COMPLETE IN TRIPLICATE) " S � k,here'in described.This application is Application is hereby made to the San Joaquin Local Health District for a permittoconstructand/o s Joaquin Local Health District. 1 made in compliance with-San.Joaquin County Ordinance No.1862 and the rul y1 r d�, s a�clwn n Exact Site Address .. Phone Owner's"Name City Address G l Sia .S �r!4r License# '.s Business-Phone � } Contractor's Name r 3 �faf Emergency Phon Contractor's Address _�•� �--�- — No rt Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 0' RECONDITION❑ PUMP INSTALLATION DESTRUCTION PUMP REPAIR 11OTH R WELL CHLORINATION WELL ABANDONMENT REPLACEMENT❑ Pit Privy { DISTANCE TO NEAREST: Septic Tank Sewer Lines .- Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Weil INTENDED USE TYPE OF WELL _ 11 INDUSTRIAL 13 CABLE TOOL - {Jia. of Well Excavation •- ❑ DOMESTIC/PRIVATE ID DRILLED Dia. of Well Casing 11 DRIVEN Gauge of Casing DOMESTIC/PUBLIC ❑ IRRIGATION 13 GRAVELPACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER -Other Information <` Surface Seal installed By: ❑ GEOPHYSICAL T` PUMP INSTALLATION: Contractor - > Ty f Pump H.P. . � i PUMP REPLACEMENT: [ff.State Work Done PUMP REPAIR: ❑ State Work Done Well Diameter Approximate Depth I L DESTRUCTION OF WELL: 1 Describe Material and Procedure �1 ' ication and that the work will be done in accordance with San Joaquin I hereby certify that l have prepared this applCounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. e of the work for Home owner or licensed agent's signature certifies the following:"I certify that in the performanc is issued, I shall not employ any person in'such manner as to become subject to workman's compensation laws of California." lowing:"I certify that in the performance of the work for which this Contractor's hiring or sub-contracting signature certifies the fol ' permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout inspection prior to grouting and a final inspection. Title: _ Date: Signed X (Dravr•Plot Plan on Rev rse ide) . t r FOR DEPARTMENT USE ONLY Q s PHASEI � 1 Date 1 � Application Accepted B Additional Comments: p s I F'n�Ipeclion Ph se II Grout Inspection to - Inspection By Date Inspection By l t July 1 &Received Fee iS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE � ❑ EACH - ❑ January 1 &Received 8y January 31 � ❑ veBy July 31 Rd lT BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT i E FEE .. LESS z PRORATION _ - PLUS , PENALTY. L OTHER OTHER X y Received by Date Receipt No. Permit No. IMF—D e F Mailed Delivered 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA 95201 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -.