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FOR OFFICE USE: LS J LJ APPLICATION JUL 21 VFor Non-Transferable, Revocable,Suspendablr ENVIRONMENTAL HEALTH PERMIT PUMP&WELL SAN _IC/',QU{N Ln-(,-'AL WATER QUALITY (COMPLETE IN TRIPLICAT) TJH Q(CT I�� Q Application is hereby madetot a nJoaquln c tth Districtfora permit to construct and/or install the work herein described.This application is made in compliance with an.jo� Cognty Ordinance No.�1186,,r the ru s and regulations of the San oa um Local Health District. Exact Site Address A4 �J , `d"{'L City/Town © Owner's Name - Phone -131 — 3 h Address 41 46city S Contractor's Name Lic se# -1-[--� Business Phone 2 Contractors Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN 11RECONDITION❑ DESTRUCTION❑ (,I WELL CHLORINATION ❑ WELL ABA ONMENT 13OTHER 11PUMP INSTALLATION ��PUMP REPAIR❑ V' 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 INTENDED USE TYPE OF WELL - ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing )KQOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ ❑ IRRIGATION 0 GRAVEL PACK Dgpth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑,OTHER - Other Information ❑ GEOPHYSICAL !l Surface Seal Installed By: PUMP INSTALLATION: Contractor ``��"" / Type of Pump ILI M. H P fl PUMP REPLACEMENT: State Work Done I I ' PUMP REPAIR: LK.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. 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 subcontracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons sub'ect to workman's compensation laws of California. 1 ca or a Grout Ins prior routing a final inspection. Signed X Title: - Date: (Draw Plot Plan on Reverse Side) (� FOR DEPARTMENT USE ONLY PHASE �n.L�v—� AY--P0.�1— Date —2�— Application Accepted By P` - 1 Additional Comments: Phase 11 Grout Inspection I Phgse Ina Inspection 5 Inspection By Date Inspection By e 2 4 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July/&Received By July 31 BILLING REMITTANCE § REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. Issilance Date Mailed Delivered APPLICANT—RETURN ALL COMES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1007 E.HAZELTON AVE.,P.O.Boa 4009 STOCKTON,CA 95201 _. l