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Appncauons will rse rrocessea wnen auomttteo rroperty t,.oml ne sure 1 o bign I ne Application. FOR OFFICE USE: 6 Alt APPLICATION (For Non-Transferable, Revocable, SuspendablL.... - 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 with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Add(As_( ess-,z ,✓��, ,pp{ e City/Town Owner's Name �Q�AS � G Ai u t i/4r .SR 14114/m4 /,, Phone Address ( Irf 17 V � C —G' City Contractor's Name 't ' r` caR License# 7;Business Phone !Ok 3 7f,74 Contractor's Address +` Emergency Phone Is Certificate of Workman's Compensation Insurance on F4 With SJLHD? Yes No I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR CK i REPLACEMENT❑ —J 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 ❑ 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 ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor / Type of Pump H.P. (o PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ® State Work Done��a/a✓. �av�✓jJ dt- .rte ✓ �Uf �ft� v- 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." --1 I ill call for a Grout Inspection r' r to outing a a final inspection. F O' Signed ` Title: n .x „1 Date: (Draw PI Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE 1 Application Accepted By ` � 1 -""� �— `�""� Date ` 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 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT �FEE=S RATION PLUS PENALTY OTHER �► !? OTHER Received by Date Receipt No. Permit No. 14.suance bate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201