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z - - -- �- ..................Vu r,vpnny-.omplezea. rse Sure To Sign The Application.- FOR pplication.FOR OFFICE USE: �� APPLICATION . (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL C (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 C made in compliance with San Joaquln County Ordinan a o. 1862 and the rules and ulations of the San Joaq I ocal Health District. /T Exact Site Address © - Cityown Owner's Name~ a T t� � / / Phone Address f� �6 city T Contractor's Name License #_J7�c��a Business Phone Contractor's Address .if "� 7 _ ' Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAI� 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 -ems ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION E3 ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ih ❑ State Work Done ` PUMP REPAIR: State Work Done _ 1 DESTRUCTION OF WELL: Well Diameter pproximate 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. Home owner or licensed�agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 forwhich this permit is issued, I shalf employ persons subject to workman's compensation laws of California." II call for a G�t t I�pection prior to grouting and a final Inspection Signed X / _ Title: Date: i. (Draw Plot Plan on Reverse Side) i� FOR DEPARTMENT USE ONLY PHASE I ;I Application Accepted By Date 10/90 Additional Comments: it ff P - Phase�11 Grout Inspection Phas Final Inspection / Inspection B I P y ��` Date _ Inspection By � Date Ii Fee Is Due: ❑ ANNUALLY i❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Janijary 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLINGREMITTANCE $ REMIT BASE EXPLANATION DATEAMOUNT DUE CHECKED DATE REMITTED _ AMOUNT FEEII LESS :._ _ PRORATION II• f`"`� ` PLUS I� 14 — PENALTY t OTHER OTHER Received by Date Receipt No. Permit No. 0 Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,�`I l� 1601 E.HAZELTON AVE.,P.O.Box 7009 STOCKTON,CA 95201 � ..� Ii: