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rPFICE USE: APPLICN 0 UN (For 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 fora permit to construct and/or install the work herein described.This application is made in compliance with San Joa�q� . c�oun Ordi ce No. 1862 a d the rulegland regulations of the San Joa K� o al Health District. Exact Site Address_ (p SLI ee _ City/Town j Owner's Name C�6,0 A?a e� zl Phone Address _ City____ .+ Contractor's Name C6 4� License k Business Phone Contractor's Address 2 _. Ali+ Emergency Phone Is Certificate of Workman's Compensation Insurance on File Nith SJLHD? Yes _ (' No TYPE OF WORK (CHECK)!• NEW WELL 11DEEPE ❑ RECONDITION❑ DESTRUCTION❑ �J WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR I� 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 ❑ 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 <<�M'�d►,c �l H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: 9 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 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I wil call for a Grout Inspecti n ri to r tin and a tt{1at inspection. / Com Signed X itle: es P,� Date: /r (Draw Plot Ian on Reverse Side) F RD PAR7 USE ONLY PHASE Application Accepted By _ Date Jv Additional Comments: _ Phase II Grout Inspection / P,ha I al Inspection e� TO Inspection By Date Inspection By i�%�YL7 Date r7 `' 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 AMOUNT FEE ! - - LESS PRORATION PLUS PENALTY OTHER OTHER 5%3 I_ 91 Ict ho ped by Date Receipt No. Permit No. I Issu nce Dale Mailed Delivered 4NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201