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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 'FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspends 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.�18/6_2 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 07, City/Town Owner's Name Phone Address Cityss �yz T Contractor's Name License# BusinePhone Contractor's Address '— Emergency Phone Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No f' TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT' 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 ❑ INP-USTRIAL ❑ 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. 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 `C is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Q 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 will call for a Grout Inspection prior to grouting and a final inspection. e Signed _ _ Title: dn!t .� Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I 3//s/R Application Accepted By - - Date Additional Comments: -- Phase II Grout Inspection Phas III F' al Inspection Inspection By Date Inspection B9Date 2 /inW Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED qAMOUNT FEE S K 14S LESS PRORATION PLUS PENALTY OTHER OTHER 05�(40 '511 l � - Received by Date Receipt No. Permit No. Issuance Date Mailed VAlered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201