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Appncauons wul tse rrocessea vvnen,uomluea rropeny t.ompleseo. tae sure I o algn I ne Appncauon. FOR OFFICE USE: APPLICATION / ,For Non-Transferable, Revocable, Suspendable� PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address hT� ,t t '✓t. r� r-1 City/Town Owner's Name "n - 6\ !� C _rt J )" Phone ?44 —/055 5-3 +. Address �l f j� G) t-'1��1 G �� City_ !� Contractor's Name _ License#3ly(, Business Phone�L 5 Y a Contractor's Address Sl- r Tf:� `I�P N �. Emergency Phone 4& (/�-!�U .� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION ❑ PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank t_( 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 C] CABLE TOOL Dia. of Well Excavation / Tc 9 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing '� ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL 94 OTHER Other Information ❑ GEOPHYS&L Surface Seal Installed By: PUMP INSTATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP RE ❑ State Work Done -DESTRUCTION OF WE6 Well Diameter Approximate Depth M r b 6 D*ribe Material a Procedure - ► ^ • ' 1' ----------- \-C,J,4C� I hereby certify that I have prepared this application and that the work wi I be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. a 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I ill call for a Grout Inspection prior to.grouting and a final inspection. Signed X Title: ' � }- Date: vC V (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date q_� �a+,� -81 Additional Comments: Phase II Grout Inspection Phase III Final Inspection Inspection By Date Inspection By 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 BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED I Ie AMOUNT FEE + y„ LESS PRORATION t PLUS PENALTY OTHER { OTHER Received by I Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201