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.� ApplicationsWill BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. IfIOR O°F CE USE: /�,� GF APPLICATION ;For Non-Transferable, Revocable, Suspendabl ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with Sen Joaquin County Ordinanc No. 1662 and the r es an regulations of the San Joaquin al Health District. Exact Site Address �f,3 to 7 Y 'A 04a %0 City/Town Owner's Name �4 Y' J&(I /�L u ✓rydto/ Phone Address /-7 S_Z4 (�' .ala r„b yr ' ri , cry ave dL( i Contractor's Nam License# IM 7 W Business Phone L' —'74 7 6 Contractors Address Oill 1.OC 9-- 3► W s-� Emergency Phone Is Certificate of Workman's Compensation Insurance on Fil With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ . DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well C3 INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Die. of Well Excavation 51 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ 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: A PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done Zt PUMP REPAIR: ❑ State Work Done O 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. 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 call for a Grout Inspection prio o u d a final Inspection. 79 Signed X e: 4/b✓ Date: (Draw Plot Pfafi on Reverse Side) FOR DEPARTMENT SE ONLY PHASE Application Accepted By Date Additional Comments: Phase 11 Grout Inspectionha IIIA �1 Inspection ^/O_ Inspection By Date Inspection By G� ? Date �_ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE 7 / LESS PRORATION PLUS n PENALTY OTHER /` ) OTHER I� `1 W -2 GLianrl eFe Received by Date,#'f y�-�N a LIE Np Permit No. issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIR;N'^ NT/�'JIZ F1' EALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Bot 2009 STOCKTON,CA Sl —