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FOR OFFICE USE: APPLICATION *4,.=or Non-Transferable, Revocable, Suspendable),owililir ENVIRONMENTAL HEALTH PERMIT PUMP&WELL 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 twiith SAn JoaquinCou ty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. :xact Site Address 11 ( QL t�c��' '%� City/Town " wner's Name =� Phone y4a—� Oss �3 b Address 4 city- -ep- yn — ,ontractor's Name I/ Ir License#Sita�-�— Business Phone's _78- ."ontractor's Address ' Emergency Phone C1�3"S3V Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No -7YPE OF WORK (CHECK): NEW WELL 2( DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ YELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ i DISTANCE TO NEAREST: Septic Tank /Ib 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 Dia. of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 ---Cl-IRRIGATION GRAVEL PACK Depth of Grout SealQ� _ CATHODIC PROTECTION ROTARY Type of Grout DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: SUMP INSTALLATION: Contractor _ ." Type of Pump -�_—.b I'm 4Z��'��1� _ H.P. PUMP REPLACEMENT: ❑ State Work Done ----� '3UMP 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. Home owner 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 taws 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 ill�calll for a Grout I ection prior t9 grouting and a final inspection. f �7 Signed X i j Title: D c i Date: f� / (Draw Plot Plan on Reverse Side) FOR DEPA MENT USE ONLY PHASE I Application Accepted By Date Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By f %' ' Date�/�� Inspection By if Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT x. BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS r PRORATION PLUS PENALTY OTHER OTHER 00 9/-, cD log* `7 `� --I a S 3 `�("A_ ?y Ir Received by Date Receipt No. Permit No. Issuance Dale Mailed Delivered APPI Ir:ANT—RFTIIRN At I COPIES TO- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON.CA 95201