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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T FOR OFFICE USE: APPLICATION .4c3—F— 2v �p Z Jon-Transferable,Revocable,Suspendable) / PUMP&WELL ` ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUAUTY Application is hereby made to the San Joaquin Local Health District lora 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 rules and regulations of the Sari Joaquin Local Health District. Exact Site Address a�'''�' w ^C "��7 0 CitylTown T _ Owner's Name �L� ��Ow � ��'"�— Phone �3 Address E 6 City Contractor's Name� ` Licensee. 7/ Business Phone Contractor's Address /V /c - _— Emergency Phone t Is Certificate of Workman s-C Compensation Insurance on file With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELLO DEEPEN ❑ RECONDITION 11 DESTRUCTIONN❑� C> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Elm PUMP REPAIR REPLACEMENT r" 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 O ❑r�/INQ USTRIAL - ❑ CA13LE TOOL Dia. of Well Excavation . Ifs DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ' ❑ GRAVEL PACK Depth of Grout Seal Q CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL I Surface Seal Installed By:. PUMP INSTALLATION: Contractor Type of Pump E— ' H.P. PUMP REPLACEMENT: ❑,State Work Don `C PUMP REPAIR: ❑ State Work'Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure ' r I hereby certify that I have prepared'.this application and that tyle work will be done in accordance with San Joaquin County ordinances,state laws, and rules and lregut tions 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." Contractors 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.¢ubiect to workman's compensation laws of California." I will call r rout na ction prior to grouting and a final Inspection. � Signed X _ "�, Title: 'w— Date:9—/�—Lv / (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By - ( Date ��p 8/ Additional Comments: Phase II Grout Inspection. - Phase III,Final Inspection Inspection By Date 1 Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 8 Received By July 31 BILLING• REMITTANCE S REMIT BASE' EXPLANATION, AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT O FEE '• LESS O✓ PRORATION I - PLUS PENALTY .� OTHER t OTHER Received by Date Receol No Permit No. las nc!Datd Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.So.2009 STOCKTON,CA 95201