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APpitcatiOns Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PLIMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with Sa1q q�ln Coun Ordinance No.1W and theu s and regulations of the San Joa uin L cal Health District_ Exact Site Address City/Town a Owner's Name Address Phone Contractor's Name CityCb Contractor's Address Ice se n#3 �I t ll Business Phone C Emergency Phone I Is Certificate of Workman's Compensation Insurance on Filo With SJLHD? Yas� TYPE OF WORK (CHECK)7 No NEW WELL DEEPEN ❑ RECONDITION U DESTRUCT OND �1 WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ REPLACEMENT IJ r PUMP INSTALLATION 11PUMP REPAIR❑ !° DISTANCE TO NEAREST: Septic Tank I , Sewer Lines Pit Privy �1 Sewage Disposal Field Cesspool/I feepage Pit -�_ Property Line Private Domestic Well Other INTENDED USES Public Domestic Well ❑ TYPE OF WELL INDUSTRIAL ❑ CABLE TOOL �1 DOMESTIC/PRIVATE Dia.of Well Excavation ; ❑ DRILLED Dia. of Well Casing 9DOMESTICIPUBLIC ❑ DRIVEN 13IRRIGATION I Gauge of Casing GRAVEL PACK Depth of Grout Seal 13CATHODIC PROTECTION ROTARY 00 00 11 DISPOSAL [3 GEOPHYSICAL Type of Grout ❑ OTHER Other Information PUMP INSTALLATION: Contractor Surface Seal Installed By: Type of Pump PUMP REPLACEMENT: ❑ State Work Done H.P. PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter (0 Describe Material and Procedure Approximate Depth I hereby certify that I have prepared this application and that,the work will be done in accordance with San Joaquin County I ordinances, slate laws, and rules and regulations of the San Joaquin Local Health District_ Home owner or licensed agent's signature certifies the following:"I certify that In the performance of the work forwhich 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 forwhich this permit is issued, I shaft employ arsons ub t to workman's Compensation laws of California." I will for a Grou spec prior uting and a final Inspection. Signed X Title: (Draw Plot Plan on Reverse Side) Date: c i PHASE FORD PARTMEN USE ONLY Application Accepted By ,yam f Additional Comments: Data v. ea Phase 11 Grout Inspection Inspection By p a e III Final Inspection Date Z Inspection By U Date Fee Is Due:❑ ANNUALLY ❑ PER UNIT Dri SITE ❑ EACH ❑ January�6 Received By January 31 ❑Jul 7 &R Y eceivetl By July 37 BASE EXPLANATION 81LLING REMITTANCE 5 REMIT DATE DATE REMITTED AMOUNT Dui CHECKED FEE AMOUNT LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. 7 IT. Permit No. Iss artCe Date APPLICANT—RETURN ALL COPIES TMallad ENVIRONMENTAL HEALTH PERMITlbERYFCESDelivered 1501 E.HAZELTON AVE.,P.O.batt 2ous STOCKTON,cA