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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) ' ENVIRONMENTAL HEALTH SPERMIr PUMP&WELL E (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is made in compliance with S .J quip County O,rdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 3 - �--EtQ City/Town C YOwner's Name tut-: e 3 S Phone Address '? ir City ' Contractor's Namo 6Q C 0 License# �/ 3 Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No h TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ' WELL CHLORINATION ❑ WELL ABANDONME OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 REPLACEMENT❑ r DISTANCE TO NEAREST: Septic Tank X01 Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line /6 Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL El /1 y INDUSTRIAL _ ❑ CABLE TOOL Dia. of Well Excavation 4 V- : } DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6# "( ❑ 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 Paaae l Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done t r 11 PUMP REPAIR: ❑ State Work Done d DESTRUCTION OF WELL: Well Diameter CI Approximate Depth D r 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 t 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 will call for aGr ut inspection prior to grouting and a final inspection. Signed X Title: Date: (Draw Plot Plan on Reverse Side) FO DEPARTMENT USE ONLY PHASEI Application Accepted By Date 2.! Additional Comments: Phase 11 Grout Inspection P s 11 Final Inspection Inspection By Date +�� Inspection By Date 4' ; Fee Is•Due: ❑ ANNUALLY - ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 +E- BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT , 'FEE '4aLESS {� PRORATION PLUS PENALTY OTHER ° 1) OTHER "*J Received by �` Date Receipt No. Permit No. ` Issuance Date Mailed Delivered —APPLICkNT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201- 3.