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Ap'olications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: 1041–td APPLICATION Coit 10 (For Non-Transferable, Revocable,Suspendable) I P• 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 with San Joaquin County Ordinance No. 1862 and the r les and regulations of the San Joaquin Local HeaJth District. Exact Site Address .57/Ir; City/Town cS Owner's Name 6 dfQ Phone 51— Address City – Contractor's Name r. License# /`137 YS Business Phone Is YG { Contractor's Address +► Emergency Phone Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN RECONDITION DESTRUCTIONO WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER © PUMP INSTALLATIONR PUMP REPAIR© 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 x ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 DOMESTIC/PRIVATE El DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal kCATHODIC PROTECTION ❑ ROTARY Type of Grout ' ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Ins lied By: PUMP INSTALLATION: Contractor F Type of Pump f H.P. PUMP REPLACEMENT: State Work Done 7, .r Aj' i 9 PUMP REPAIR: 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 thework 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:"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 11 call for a Grout Inspection to ro pknd a 'nal inspection. Signed X le: Date: (Draw Plot P an on Reverse Side) FOR DE ARTMENT USE ONLY PHASE Application Accepted By n �^ Dated__41 Additional Comments: ,Ph s I Grout Inspection Phase Ili Finn l Inspection Inspection sy Date Inspection By 7 Date Fee Is Duei ❑ ANNUALLY ❑ PER UNIT 1� PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS lei PRORATION PLUS PENALTY OTHER OTHER V Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES 16011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201