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Applications Will Be Processed When Submitted Propenyl.vmP1,vt= • EFOF OFFICE=USE: APPLICATION / f. .or Non-Transterabte, Revocable,Suspendable)' ? pUMp &WELL � ENVIRONMENTAL HEALTH PERMIT WATER QUALITY I. "(COMPLETE IN TRIPLICATE) District for a permit to construct and/or install the work herein described.This application is Application is hereby made to the San Joaquin Local Health mNo. 1862 and the rules and regulations of the San Joaquin Local Health District. made in compliance with San Joaquin County Ordinan City/Town Exact Site Address �— s Phone Owner's Name City AddressS L Contractor's Name License# Business Phone ` Emergency Phone Contractor's Address �c �.�.�s No ` Is Certificate of Workman's Compensation Insurance on File W' h SJLHD? Yes { TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTIO�N,❑� v" WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION td` 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 I INTENDED USE TYPE OF WELL ❑�,,,, INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation f "DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 'r ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal installed By: PUMP INSTALLATION: Contractor r � r 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 I I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 1 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 far which this permit is issued, I shall employ persons subject to workman's compensation laws of California." kt't'd for a Grout Inspection prior to grouting and a final inspection. ,�., L(f1 Sig d X Title: Date: � 0 _ (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE Ic / �G Dat e��.3 Application Accepted By; Additional Comments: Phase It Grout Inspection P se Ill Final specti Inspection By Date Inspection 8y •mat ✓� ^�� Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE C1 EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 BASE EXPLANATION BILIING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT µ O Z. FEE i LESS PRORATION PLUS PENALTY OTHER OTHER ` Ll Received by Date Receipt No. Permit No. I suanc Date!`.f\ Maited Delivered J 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKT9N,CR 95201 APPLICANT —RETt1RN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES