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Applications,.Will Be Processed When Submitted Properly Completed. Be SureC0 Sign The Applicationn. EMP ZTR APPLICATION _ '•' /a/ _ Non-Transferable, Revocable,Suspendable) PUMP&WELL 1 ENVIRONMENTAL HEALTH PERMIT CAtE) LSYD.VE'.e/OCoE /7 WATER QUALITY ii,' Appiicatio�is hereby made to he San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in�Q mpliance with S.ann Joaquin County Ordinancq No. 1862 and the rules and regulations of the San Joaquin.Local Health District. a, Exact SitcdAddress y�ijJ(L(tin. �l�L ��C�,�. l ,i..a`Jr�P� City/Town Owner's Name hf�/�5; / Phone Address :_City -. Contractor's Name ,.8 License N_O2V/ Business Phone Contractor's Address Emergency Phone .'S �-0�;7/ _ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X No i TYPE OF WORK (CHECK):: NEW WELL)( DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ - WELL CHLORINATION I) WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank ��r�', Sewer Lines Pit Privy _� T Sewage Disposal Field_/ Cesspool/Seepage Pit Other Property.Line_Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL .� �❑(INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation ,yam DOMESTIC/PRIVATE C3 DRILLED Dia. of Well Casing � ✓ - —. ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f� ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal h� ❑ CATHODIC PROTECTION )4 ROTARY Type of Grout - ❑ DISPOSAL ❑ OTHER 1 Other Information____1 ❑ GEOPHYSICAL — Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump, H.P. PUMP REPLACEMENT: 4 State Work Done ., PUMP REPAIR: .- 0 State Work Done DESTRUCTION OF WELL: r .Well Diameter.(, .4 Approximate Depth f Describe Material and Procedure ti I hereby certify that I have prepared this application and thiel 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 perform$nce 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 `a�'11 fffoorraa�`Grrrout Inspect n prior to grouting and a final inspection. Signed X 4 �r Title: ��• Date: ✓rte _. z ( aw Plot Plan on Aeverse.Side) F4PRRR DEPARTMENT USE ONLY ,Q PHASE I Application Accepted By, Date ��T- I �'v— Additional Comments: ti , Ph e I rout InspectionPhase IIal Inspection s I F Inspection By�� ZrAe � Date_p "�3 �� Inspection By Date Fee Is Due,❑ ANNUALLY Q PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 d Received By July 31 REMIT BASE' EXPLANATION BILLINP REMITTANCE S AMOUNT DUE CHECKED H's DATE DATE REMITTED AMOUNT FEE <2 yJ LESS S, r PRORATION PLUS PENALTY .. OTHER OTHER Received by 10ale I Receipt No. Permd No I iled Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE..P.O.Bo.21109 STOCKTON,CA 95201