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F FOR OFFICE.USE: ANF'LIGATIll ("t?r Non-Transferable, Revocable, Suspendable) PUMP&WELL `ENVIRONMENTAL HEALTH PERMIT i (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install tk 1 escrt d.This application is made in compliance with San JoaquinDunt Ord' ce No. 18,62 an a rules and regulations'of the San Joaquin Local Health District. . Exact Site Address . nt , . City/Town 1 Owner's Name f'`Ir L�) 01,d Phone_ i Address09 City Contractor's!Name License#� � Business Phone I Contractor's Address _ Emergency Phone Is Certificate of Workman's Compensation insu ce on Fit ith SJLHD? Yes No TYPE OF WORK {CHECK):. NEW WELL DEEPF9 RECONDITION❑ DESTRUCTION❑ it WELL CHLORINATION ❑ WELL ABANDON NT ❑ OTHER ❑ PU P INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other _ . j Property Line Private Domestic Well Public Domestic Well INTENDED USE �T '�E OF WELL 01 IN��TRIAL Ir CABLE TOOL Dia. of Well Excavation R"DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 42 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing l _ ❑ 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 Type of Pump H.P. t. PUMP REPLACEMENT: ❑ State Work Done 'J 1, PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 5,t hereby certify that 1 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 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 permit is issued, I shall employ per ons subject to workman's compensation laws of California." I will ca ora Grout Inspect! fort grouting and a final insi �. �j f Signed X Title: _B90-.2-Ar/ bate: �(Dra, an on Reverse Side) OR DEPARTMENTUSEONLY PHASEI Application Accepted By Date Additional Comments: h II Grout Inspection P e II final Inspection Inspection By� atm � � Inspectioll Fr Dat /�/ ,_ / Fee IS Due: 13 ANNUALLY PER UNIT ❑ PER SITE 11 EACH El January 1 4ceived-By January 31 - El July t &Received By July 31 REMIT BILLING REMITTANC i $ BASE EXPLANATION AMDUNT DUE CHECKED DATE DATE REMITTED AMOUNT � 3FEE � ! LESS PRORATION �P PLUS L{ PENALTY r OTHER t i OFHER Received by Date Receipt No, Permit No. Puanciyl Mailed Delivered { APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952011