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lug ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure 7o Sign The Application. FOR USE: APPLICATION ------------- (For Non-Transferable, Revocable, Suspendable) I! ENVIRONMENTAL HEALTH PERMIT Pump&Wal (COMPLETE IN TRIPLICATE) WATER QUALITY a 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 Count Ordinance No. 1 2 nd the rules and regulations of the San Joaquin Local Health District, Exact Site Address City/Town Owner's Name Phone I s Address City �. Contractor's Name License# Business Phone Contractor's Address _24Emergency Phone Isl Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_.._ _ No p �� TYPE OF WORK (CHECK): NEW WELL� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ U`) WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ Df STANCE TO NEAREST: Septic Tank c, e�� Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit 1420- Other i Property Line Private Domestic Well Public%Domestic Well INTENDED USE TYPE OF WELL ,❑ INDUSTRIAL t�- KCABLE TOOL Dia. of Well Excavation- DOMESTIC/PRIVATE DRILLED Dia. of Well Casing. A I.DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 13 IRRIGATION IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑i CATHODIC PROTECTION ❑ ROTARY Type of Grout 01 DISPOSAL ❑ OTHER Other Information ❑(GEOPHYSICAL Sur,#ac�eal stalled By: I PUMP INSTALLATION: Contractor Type of Pump H P P IMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done` �* DESTRUCTION OF WELL: Well Diameter { f y Approximate Depth �,�Des Ibe Material 1130 i dCrUedure I hereby certify that I have prepared As application and that the work will be done in accordanVe with San Joaquin County 4 ; ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. .-�--„ cert_�.t Home owner or licensed agent's§ignature certifies the=tallowmg: f certify thaf in the per ormance ofthework forwhich this permit ' is issuetl I shall not employ any person iin such manner as to become subject to workman's compensation laws of California," Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this 1 permit is issued, I shall employ persons subject-to Workman's compensation laws of California." t I I will all for a Grout Inspection r r to ro�ri and a�final-ins_-inspection. P P� 9. 9-. P . { Signed X 9. a A Title: �d � -.-�� Da (Draw Plot Plan on Rete:verse Side) " i FOR DEPARTMENT uSE,ONLYS PHASE I i Application ,ccepledBq - f'� rj^ -8 e ,may Date Additional GommeRts:' 'r t Phase It Grout Inspection ection v4/_ t• + ��,, r as Insp cttan Insp ction By da Dal 1-11" M1pecfion By - Date Fee Is e: ❑ ANNUALLY - -'PER.UNLT .❑ PER SIT ❑ EACH ❑ January 1 8'Received By January 31 ❑ July 1 8-Received By July 31 A E E P •tt7N BILL N(3;—a EMITTANCE ✓'�$ REMIT , ' -- DATE DgTE"'�+�e_ REMITTED AMOUNTJDUECHECKED- AMOUNT FEELESS �..' I PRORATION t'es't PLUS ! I PENALTY OTHER I - - . I OTHER Received by Date Receipt No. Permit No. Issuance Dat Mailetl Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 'I 1601 E.HAZELTON AVE.,P.O.ao■2009 STOCKTON,CA 96201