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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION - (For Non-Transferable, Revocable, Suspendable,y PUMP &WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fo r a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin Co�/u�1,t�y{Ordinance No 1862 and the rules and regulations of the San Joe Lin Local Health District. Exact Site Address ��e /._L_) ]-1-c-/ 1 City/Town /'-GCOI Owner's Name Phone Address �,4-f Pe—J. City Contractors Name License#,:2:?0S�V3 BusinessPhonei U_S-//9,5 n Contractor's Addrerf�lcrl�<i2')Emergency Phone 54"i -� 7/ i Is Certificate of Workman's Compensation" Insuranceon File With SJLHD? Yes X No TYPE OF WORK (CHECK): NEW WELt,.ca DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 REPLACEMENT❑ y DISTANCE TO NEAREST: Septic Tank J35 Sewer Lines Pit Privy Sewage Disposal Field X35' Cesspool/Seepage Pit Other �--I Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ,,❑,/INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation )a DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing a y� P ✓e. ❑ DOMESTIC/PUBLIC r❑3 DRIVEN Gauge of Casing ❑ IRRIGATION �r�LsGRAVEL PACK Depth of Grout Seal 13 CATHODIC PROTECTION w,ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: r� PUMP INSTALLATION: Contractor Type of Pump H.P. 1 PUMP REPLACEMENT: ❑ 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 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 subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final Inspection. (� Signed X a Title: f:3&& A Date: II /u -kf J l J (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By Date Additional Comments: - I t Inspection Phase III Final Inspection Inspection By Date �"� v Inspection By 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 It AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY _ OTHER OTHER Received by Date Receipt No. Permit No. isa,iance D to Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201