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Applications Will Be Processed When Submitted Properly Completed.Be Sure ToSignTheApplication. FOR OFFICE USE: nAPPLICATION or 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%l San Joaquin County Ordnance NQ_ 1.862 and the es and regulations of the San Joaqui.}Local Health District. Exact Site Address City/Tow�n7 /FC i /DSI Owner's Name N PhoneIA f f T - '�f' — 6•�L� Address City Contractor's Name License#.?2 ? Business Phone Contractor's Address,57 lit Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo } TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIONESY DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ ,Z REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank - i Sewer Lines <0 I,- _ Pit Privy Sewage Disposal Field%�� Cesspool/Seepage Pit Other — Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL t, ❑ INDUSTRIAL 01 CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /0 will IRRIGATION ❑. GRAVEL PACK Depth of Grout Seal J` ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout '�'-- ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: c' 26i:l 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-Procee ure --- W— I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f,� 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." Contractors.hiring or sub-contracting signature certifies the following:"']certify that in the performance of the work for which this permit is issued, I shall employ perso s Jett to workman's compensation laws of California." I will call for a rout 1 ec c�n.pr' f. uting.anih a final Inspection. j Signed Title: n1 Date:. 6 (Draw Plot Plan on Revers ide) FOR DEPARTMENT USE ONLY �j i p. PHASE I � Date L— b-:Rx Application Accepted B rt ° ,..,.�. ems'^ Additional Comments: Phase II Grout inspection h se ll Ftnal-Inspection r1 Date Inspection By Date k7"°3�� Inspection By .(Aye Fee Is Due: ❑ ANNUALLY []-PER UNIT ❑ PER SITE El EACH ❑'January 1 &Received y January 31-r ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ' DATE DATE REMITTEIJ AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No Permit No. suance D to Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201