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'r `FOR OFFICE USE: _.• .. o v�APPLICATION~V.Y~ y v 7 �rr•.��.. l'. Non-Transferable, Revocable,Suspendable) F. ENVIRONMENTAL HEALTH PERMIT PUM-1P&WELL t (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 made in compliance with San Joaquin ounty Ordin ce No. 18 2 an a rules and regulations of the San Joaquin Local Health District, Exact Site Address . ! City/Town !0 Owner's Name Phone + Address City Contractor's Name License#-0:Z 7— "I/ Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Ensu ce on Fil ith SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDON NT ❑ OTHER ❑ PU P INSTALLATION E] PUMP REPAIR❑ REPLACEMENT© ,i DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy II Sewage Disposal Field Cesspool/Seepage Pit Other II Property Line Private Domestic Well Public Domestic Well INTENDED USE TAPE OF WELL f �� 13INTI LISTRIAL CABLE TOOL Dia. of Well Excavation ! , DOMESTIC/PRIVATE ❑ DRILLED •� s Dia, of Well Casing 42 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION 11k; GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ ❑ DISPOSAL ❑ OTHER Other Information I` ❑ GEOPHYSICAL Surface Seal Installed By: h PUMP INSTALLATION: Contractor 'h Type of Pump PUMP REPLACEMENT: ❑ State Work Done + PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth I ? Describe Material and Procedure 1 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. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit t. 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this J permit is issued, I shall employ per ons subject to workman's compensation laws of California." I! I will cay7or a Grout Inspectsp. or 1 grouting and a final inspec' Signed X ;0 iali�l Title: Date: (Draw of Plan on Reverse Side) PHASEI OR DEPARTMENT.USE ONLY Application Accepted By r Additional Comments: _ - Date -� If Grout Inspection ¢-� I p e II final Inspection :E Inspection By at O UInspectRo? By Dat Ah41 Fee IS Due: 11 ANNUALLY P�UNIT ❑ PER SITE ❑,EACH ❑ January 1 Lceived By January El July 1 8 Received By Jufy 31 BASE EXPLANATION BILLING 4EIA'TTANC $ REMIT DATEREMITTED AMOUNT OUE CHECKED uAMOUNT FEE LESS ` PRORATION PLUS PENALTY k OTHER 01 ii OTHER Received¢Y Date �� Receipt No. Permit No_ uanc ate Mailed Delivered .O.Box 2009 STOCKTON,CA 9S201: APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.NAZELTON AVE.,P '