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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign They Application. t FOR OFFICE USE: APPLICATION Mon-Transferable,-.Revocable,Suspendable) / PUMP&WELL 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 Ordinence No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address �I to C' -S.L.,�rY�9=:4 City/town Owners Name I1J'fA ° f �,yC�.d�--w 'I Phone' %d-�� "Z Address Tom- �� - City - �_ CIA Contractors Name �-C� 3-+ License p 54 . `E'7 1 Business Phone3� y r ) Contractors Address _yxn ✓� T Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ % WELL CHLORINATION d WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION m/PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Seplic 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 d ❑ IN �VRIAL ❑ CABLE TOOL ' Dia.of Well Excavation U 83'DOMESTIC/PRIVATE - P DRILLED Dia. of Well Casing Q DOMESTIC/PUBLIC b DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information O GEOPHYSICAL - Surface Seal Inst By: By: PUMP INSTALLATION: Contractor CcAg--+/ il-- Type of furnp z ), i—GH.P. Z_ PUMP REPLACEMENT: ❑ Sta(A Work Done PUMP REPAIR: ❑ Stale WOrkbone 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, stele laws, and rules and regulationi:'of the San Joaquin Local Health District. Homeowner or licensed agent's.efgnatum 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 forwhich this permit is issued, 1 shall employ persons subject to workman's compensation laws Of California:' at a Grout Inspection prior to grouting and a final Inspection. . Signed'I 1/% Title: c! '.n ✓`— .Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE - _ Application Accepted By 7-/ / Date Additional Comments: Phase 11 Grout Inspection t Ph e lly Final Inspection Inspection By_ Date .Inspection By I, Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE• '❑ EACH ❑ JatlaBry 1 6 Received By January 31 ❑ July 1 d ReceNe0 By July 31 BILLING REMITTANCE S REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT g FEE CIS LESS PRORATION PLUS > PENALTY OTHER OTHER RaceNed by Date Receipt Noa and No luue Data Mailed _ Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Be.2009 STOCKTON.CA 95"