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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 Site Address, -�/ `--,f City/Town/AJC c �`Z/�ri Owner's Name _ it & 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 1=<e Ct Sewer Lines INTENDED USE ❑ INDUSTRIAL 04"60MESTIC/PRIVATE ❑ DOMESTIC/PUBLIC ❑ IRRIGATION ❑ CATHODIC PROTECTION ❑ DISPOSAL ❑ GEOPHYSICAL PUMP INSTALLATION: PUMP REPLACEMENT: PUMP REPAIR: DESTRUCTION OF WELL: Sewage Disposal Field Property Llne� s"F I vy Cesspool/Seepage Pit Other Private Domestic Well –� Public Domestic Well TYPE OF WELL ❑ CABLE TOOL Dia. of Well Excavation ❑ DRILLED Dia. of Well Casing ❑ DRIVEN Gauge of Casing ❑ GRAVEL PACK Depth of Grout Seal ` I ❑ ROTARY Type of Grout � ❑ OTHER Other Information v Contractor !// LL Type of Pump 7r. ❑ State Work Done ❑ State Work Done Well Diameter Describe Material and Procedure Surface Seal `lns�alled/By: S 1 t Approximate Depth 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 LocalxHealtb_ District. Homeowner or I!cerise d 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 groutin�Ptot and a final inspection. Signed Xf � Title: t/`•' S � l.� P� • Date: (J (Drawlan on Revers Side) FOR DEPARTMENT USE ONLY PHASE I (� �^�s,^� {�-� Application Accepted By "�j`Date �– �'_/v Additional Comments: Phase II Grout Inspection Ph a Incl Inspection Inspection By _ Date Inspection By� Date 7— // Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jan BASEI EXPLANATION I BDATEG I REMITTANCE DAT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. - APPLICANT—RETURN ALL COPIES TQ ENVIRONMENTAL HEALTH PERMITISERVICES 1 S Received By January 31 S REMITTED 10 ❑ July t d Received By July 31 �-IECHEC;KEID T AMOUNT IssLanct Date Mailed Delivered 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON. CA 95201