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Applications.vvm be Processea when ,uornniea Properly uompletea. be ,Ure I o bign I ne Applicauon. FoR OFFICE Use: APPLICATION # (011 lb (For Non-Transferable, Revocable, Suspendable) i { ENVIRONMENTAL HEALTH PERMIT PUMP&WELL F (COMPLETE IN TRIPLICATE) WATER QUALITY 1, Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thew rk herein erein described.This application is made In compliance with San Joaquin County Ordinance No. 182 an the rules and regulations of the San Joaquin Local Health District. Exact Site Address ° r" - —a ' City/Town tpOwner's Name Phone AddressRx Contractor's Name, �d '� `"' .. License ff � yBusiness Phone Contractor's Address _. ? ,�. F-i� ,,� Ids,—, Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes k No F TYPE OF WORK (CHECK): NEW WELL ElDEEPEN ElRECONDITION 11DESTRUCTIONWELL CHLORINATION 11WELL ABANDONMENT 13OTHER 11PUMP INSTALLATION ElREPLACEMENT 11PUMP REPAIR DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing i ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ 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. f mss" PUMP REPLACEMENT: ® State Work Done PUMP REPAIR: ElState Work Done d% DESTRUCTION OF WELL: Well Diameter. Approximate Depth to 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. Homeowner 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will yall for a Grout Inspection pr' r to routing nd a fin !I" inspect' x Signed X :r /" Date: (Draw Plot P f1 o - everse Side) OR DEPARTME T USE ONLY � PHASE I � � ' Application Accepted By C� Date � Additional Comments: Phase 11 Grout Inspection Phase 111 Final inspection Inspection By Date Inspection By _ 8Dat Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received A 31 1 BASE EXPLANATION BILLING . REMITTANCE $ REAMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS F, PENALTY OTHER OTHER i M�-- (c k F"i Received by Date Receipt No. Permit No issuance Dale Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 }