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r r Appllcatlans Will Be Prad..r..ed When Submitted Property ComQleted.Be Sure ign The Application. FOR OFIsICE USE: APPLICATION .i (For Nan-Transferable,Reracable,Suspendabie) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT WATER QUALITY ' {COMPLETE IN TRIPLICATE} Local HBalth Districtfor a permit toconstruct andlor install thework herein described.This application Is Application is hereby madeto the San Joaquin made in compliance with San Joaquin County rdi ante No.1 2 and lhe•rules and regulations of the San Joaquin Local Health District. City/Town . Exact Site Address phone Owners Name :. s City_ Address d ' License# 8usineas Ptlone i Contractor's Name D: F �'Emergency Phone' ` I Contractor's Address No _ Is Certificate of Workman's Compensation in urance on File With SJLHD? Yes - _ TYPE OF WORK (CHECK): NEW WELT DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ❑ WELL ASAND LAMENT ❑ OTHER'13 PUMP INSTALLATION❑ PUMP REPAIR E3 WELL CHLORINATION W LLLxxx+++ REPLACEMENT❑ 114 Pit Privy Sewer Lines 5 vY DISTANCE 70 NEAREST: Septic Tank Other Sewage Disposal Figld CesspoollSeePa9e Pit�-- - Property Llne fob Private Domestic Well s�_� Public Domestic Wal INTENDED USE —TYPE OF WELL tf El INDUSTRIAL - Q CABLE TOOL Dia.of Well Excavation re DOMESTiOtPRIVATE ❑ DRILLED Dia.of Weil Casing LJ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f S� ❑ IRRIGATION GRAVEL PACK Depth of Grout Seat AROTARY Type of Grout t6l�fc 11 CATHODIC PROTECTION Other Information ❑ DISPOSAL - ❑ OTHER 12 GEOPHYSICAL Surface Seal Installed PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ 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. Horne owner or licensed agent's signature certilles the tollowing:"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 persons subject to workman's compensation laws of California" permit is issued, I shall employ I call f r a ti a r to grouiing and a final Inspection. Title: Date: Signed X { • (Draw Plot Plan on Reverse Sidej j FOR DEPARTMENT USE ONLY p PHASE I Date I�— �—a Application Accepted By 1, Additional Comments: I Grout inspection� P I allns Dation Inspection Date,i�r- - inspection Vffled Date -•- 15.�_-.."_ I By Fee Is Due:❑ NNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1& y January 31 ❑ July 1&ReceiveRdEMITWy 3i - BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMtTT@D AMOUNT 8 g FEE - LESS ' PRORATION PLUS ' PENALTY - OTHER OTHER Permit o. - I oncel. to Mailed Delivered Received by Date Receipt No. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITl6ERYICES 1601 S.HAZELTOM AVE..P.O.Box 2099 STOCKTON,CA 9