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•apprwauons •vn1 oe rrvicessea rrnerl auIJImueu rropeny a,ompn:tea. oe QUM I u wgn I ne mppncat€on. USE: APPLICATION For Non-Transterabte, Revocable, SuspendablenPUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin Co my Or finance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address City/Town _ rCc C Owner's Name / Phone � '.ZIF7M Address /S•' city. Contractor's Name _, cGfcense#3Gy Business Phone Z7 Contractor's Address _" i1 �_ /�32 Emergency Phone7r� 175 - Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13 RECONDITION DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT,K 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 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout L FJ ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: A PUMP INSTALLATION: Contractor Type of Pump H.P. G+ PUMP REPLACEMENT: „,R,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 LU 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 thework 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 pnol"'to grouting and a final inspectuoa. _ f Signed X Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Application Accepted By - Date Additional Comments: Phase II Grout Inspection Ph se I Final Inspection`` f Inspection By Date Inspection By Date 23' i { 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 LESS PRORATION PLUS PENALTY OTHER OTHER - Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201