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'OR OFFICE USE: APPLICATION For Non-Translerable, Revocable,Suspendable PUMP &WELL ENVIRONMENTAL HEALTH PERMIT WATER QUALITY O (COMPLETE IN TRIPLICATE) -41 Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or in stali the work.herein described.This application is made in compliance with San Joaqu.n Cou Ordinance No.1862 and).Ke rules and re uta 'ons of the San Joacyu n L alth District. Exact Site Address - I O ?SIF ,„ City/Town r o - Owner's Name J G a F��+ . - Phone � Address 1 City Contractor's Name License# Business Phone Contractor's Address �_ Emergency Phone Is Certificate of Workman's Compensation Insurance on File V PA SJLHD? YesTYPE o OF WORK (CHECK): NEW ON ❑ WELL,ABANDONMENT ❑ OTHER 11 RECONDITION❑P INSTALLATION❑ WELLO PURLE C o P Y REPLACEMENT❑ ♦ too I *o wlmousr S7-"CTV0- Q—, 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 �{ ❑ INDUSTRIALCABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing (r ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r� IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal v CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: 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 1 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. 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 certfrthat in the performance of the work forwhich this permit is issued, I shall employ persons subjedt to workman's compensali'oniflaws of California." I will Cal 14r 1 ectio r to grouting and a final Inspectlo Signed X Title: Dat i (Draw Plot Plan on Reverse Side) i FOR D PART ENT USE ONLY PHASEI Application Accepted By ^' "1 Date Additional Comments: Phase y Grout In ectio / �-'f f hase F al Inspectiond"1 Inspection By it SDe r' pecJtA�7_B Date f -------------- Fee —.------1. Fee IS Due: ❑ ANNUALLY ❑ PER UNIT .nWPER SITE EACH January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 } - - REMIT PI` BASE 'EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT +r FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No Permit No. - Inu nce Date Mailed Delivered APPLICANT=RETURN ALL COPIES TO: - ENVIRONMENTAL REALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,-CA 95201