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FG. OFFICE USE: APPLICA �� `� � ] r Non-Transferable, Revo 5uspe❑❑ndffable) ENVIRONMENTAL HE LTH P�R111 PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY �❑ �I\Q1 ]N �ii��i` s Application is hereby made to the San Joaquin Local Health District fora permit toconstMtaa tl�t�e h JereindescribPd.Thisapplication is made In m &� compliance with San Joaquin Count Ordi ante No. 1862 and the r Y � ales and re�i�ti-ons of the Sa J uin La Health District, Exact Site Address_Z01/6� �, City/Town Owner's Namea ^ Phone 6 Address Contractor's Name License# ! J�.�� *'Business Phone � S Contractor's Address _fp Emergency Phone . c _ ` Is Certificate of Workman's Compensation InsuranA on File With SJLHD? Yes r No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ x- WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR REPLACEMENT IJ G,v 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 w ❑ DOMESTIC/PRIVATE © DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing El IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal i ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: ` PUMP INSTALLATION: Contractor Type of Pumpie H P 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 sub-contracting 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 wil c II for Grout!i2epse;Jah prior to grou ng and a final inspection. Signed X Title: Dale: (Draw-k,4an on Rever Side) FOR DEPARTMENT USE'ONLY PHASE 7 Application Accepted By Date —SSG Additional Comments: Pha a II Grout Inspection y��phase 1 Final Inspection _ Inspection By Date Inspection By J�J Pl� lyr�,27ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE .REMITTED AMOUNT FEE LESSOil- PRORATION PLUS PENALTY I OTHER OTHER Received by Dale Receipt No, Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bore 2009 STOCKTON,CA 95201