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Applications Will Be Processed When Submitted ProperlyCompleted. BeSureTo SignTheApplication. G , FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELD � 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 Joaquin County Ori No. 1862 and the rules and regulations of the San Joaquin Local,Health District. �� Exact Site Address cCity/Town —� Owner's Name vz� Phone Address City Contractor's NameLicense# 0�?0 2/.3 Business 5Ph ,, Contractor's Address =0— Emergency Phone Is Certificate of Workman's Compensationn urance on File With SJLHO? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tan l wer Lines_J�_ Pit Privy Sewage Disposa Field_ il -�- Cesspool/Seepage Pit _� — Other Property Line. Private Domestic Well_l/'—Public Domestic Wel! INTENDED USE TYPE OF WELL d INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 4 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 0, ❑ DOMESTIC/PUBLIC �❑y DRIVEN Gauge of Casing O ❑ IRRIGATION JAL GRAVEL PACK Depth of Grout Seal � �. 1:1 CATHODIC PROTECTION ROTARY Type of Grout b _e OF g 11DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: p'��,� l( Contractor 1 Type of Pump H-P, 10o PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done �Cf `f 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. T Home owner 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call r a Gro t Inspection prior to grouting and a final ins coon. Signed X Title: Date: (Draw Plot Plan on Revers Side) F DEPARTMENT USE ONLY PHASE ] Application Accepted By Dat E Ad itional Comments: Ph a Grout ection�� Phase Final pectlon Inspection By IWX ate / Inspection By G Date �� 7 � Fee Is Due: El ANNUALLY [3 PERU IT ❑ PER SI E ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE ^� LESS PRORATION PLUS PENALTY OTHER OTHER Received by ate Receipt No. Permit No Issu n e Dae Mai4ed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA%5201 .