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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. ) 1 FOR OFFICE USE: 'APPLICATION `Q/ 3.; J Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY f Application is hereby made to the San Joaquin Local Health Districtfora permittoconstruct and/or install thework herein described.This application is made i :Ompliance with Sa Joaquin County Ordinan No. 1862 ark the r es and regulations of the San Joaquin Local Health District. d Exact S�leAddress ��7`.3 /�� —J s ' City/Town �/ I Owned Name .( _ _ Phone- y�.�,C�.' �.Z I1II Address _, _ City Contractors Name lt�i� '�_ License R �/'�. Business Phone /act . Contractors Address _ Emergency Phone 'S�s't7_:I7/ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELLX DEEPEN ❑ RECONDITION DESTRUCTION❑ "V WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑, PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ �n / DISTANCE TO NEAREST: Septic Tank _.,f4!.,�_ Sewer Lines Pit Privy. Sewage Disposal Field /DD Cesspool/Seepage Pit Other Property Line - Private Domestic W01I Public Domestic Well r INTENDED USE TYPE OF WELL ❑ INDUSTRIAL Q CAQLE TOOL Dia.of Well Excavation w DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �/ I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ///✓�lVr ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal / ❑ CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL 'fOTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: p State Work Done PUMP REPAIR: l] State Work Done 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,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 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." I 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 II for a Grout 1 Deet n prior to grouting and a final inspection. Signed X .�� Title: ' Date: / 0 - (Pfaw Plot Plan on Reverse Side) qy FOR DEPARTMENT USE ONLY PHASE I Application Accepted B , V l Date Additional Comments: Phase III Final Inppectioo Inspection B/dDateInspection on B �VEY e/ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 d Received By July 31 BILLING REMITTANCE S REMIT BASE EXPLANATION :DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER fit— -19 � ` 11113 1 il 0 � o b��-� Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 25201