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Applications Will Be Processed When Submitted Properly Comf eted.�Be Sure To Sign The A .FOR OFFICE USE: APPLICATION g Pplfcation. (For Non-Transferable,Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is herebymadeto the San Joaquin Local Health District fora permitto construct and./or install the work herein described.This application is made in compliance '/� Oaq my in 1862 and the rules and regulations of the San Jo tn—Locall a fth District. Exact SiteAddress,-�/ `-- ,f City/Town /AJC c � s Owner's Name_ it& L Phone Address Ity Contractor's Name icense# �usiness Phone Contractor's Address Emergency Phone ---- � Is Certificate of Workman's Compensation InsU, ce on File With SJLHD? Yes�Z___ No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ *�J WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR C REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines./1` Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Llne�s"F Private Domestic Well —� Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation &"60MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I ❑ CATHODIC PROTECTION ❑ ROTARY � Type of Grout � ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Inslied By: PUMP INSTALLATION: Contractor Type of Pump 7r PUMP REPLACEMENT: State Work Done Y, PUMP REPAIR: ❑ State Work Done t r 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 LocalxHealth_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." Coniractoes 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" I will call for a Grout Inspection prior to grouting and a final inspectio/n. Signed Xf" .-�r ��--� Title: t/`' Date: (J (Draw Plot Plan on Revers Side) k FOR DEPARTMENT USE ONLY t PHASE I (�� Application Accepted By y `,^J"1l`s,^ A 11 Date A Additional Comments: Phase II Grout Inspection 1 Ph a Inallnspection / Inspection By _ Date Inspection By Date 2 i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jan,jary 1 S Received By January 31 ❑ July t d Received By if, BASE EXPLANATION BILLING REMITTANCE $ REMIT (I DATE DATE REMITTED AMOUNT OUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Dig G(` Received by Date Receipt No. Permit No. I55 aRC Date Mailed Delivered + APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.MAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201