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Applications Will Be Processed When Submitted Properly Completed. Be Sure To_Sign The Application. FOR OFFICE USE: - APPLICATION JCC y Non-Transferable, Revocable, Suspendable). PUMP&WELL ENVIRONMENTAL HEALTH PERMIT --2- (COMPLETE IN TRIPLICATE) WATER QUA.TY 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 Ordinance No,4862 and the rules and rejulations of.the San Joaquin Local Health District. Exact Site AddressfJ�. C?�+ `5�41.�. �T! �_ CityfTown a1�- . /J j2Z_ Owner's Name �S1L1 C Jn�1" °� (�f'�-d-„'r'�.eyti�"a� Phone ,L(n � d Address -/Q fz� 7 Contractor's Name ` .^i7:w1, License a, L Business Phone t,43-S-� � Contractor's Address, - 6I; "K ,_ Emergency Phone- Is Certificate of Workman's Compensation Insurance on File With SJLHQ? Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONN❑ 1 WELL CHLORINATION ❑ WELL ABANDONMENT ❑� OTHER ❑ PUMP INSTALLATION 6----'PUMP REPAIR REPLACEMENT❑ - , ' ' . DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal FieldCesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ IN.WSTRIAL ii ❑ CABLE TOOL Dia. of Well Excavation r LO'DOMESTIC/PRIVATE ❑ DRILLED Dirt. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIyEN _ - Gauge of Casing ❑ IRRIGATION I] GRAVEL PACK Depth of Grout Seal . Cl CATHODIC PROTECTION ❑ ROTARY e.1r Type of Grout ❑ DISPOSAL ❑ OTHEp' Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: ContraFlor� ,pr Type III Pump H.P. PUMP REPLACEMENT:” ❑ State Work Don PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: We(I Diameter i ,' ' ' , Approximate Depth Describe Material and Procedure - nn ✓ I 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. Homeowner or licensed agent's signature certifies the following:"I certitythat 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 {hall employ persons subject tp workmar)'s compensation laws of California." I will all for a Grout Inspection prior to grouting and a final Inspection. . Signed t' Title: I'lT� Date: —� 3 ' (Draw Pilot Plan on Reverse Side) , FOR DEPARTMENT USE'ONLY PHASEI 3 Application AccePteq By '' Date / z Additional Comments: Phase II Grout Inspection Fh e R I"naall�Inss,,ppection Inspection By Date Inspection By /J�� ,7 % ate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January.1 d Received By January 31 ❑ July 1 8 Received By July 31 REMIT BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATIONDATE DATE REMITTED AMOUNT FEELESS s PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit No. itisuance ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201