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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �S I/ 1 FOR OFFICE USE: APPLICATION 7 —/ ` �OT or Non-Transferable,Revocable, SuspendabIt PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal I the work herein described.This application is made in compliance with San Joaquin pounty O dinanc�e7No. x,862 and Mules and regulations of the San Joaquin Local Health District. bb Exact Site Address —7'Z�t"7� /.c_.l �c City/Town Owner's Name Yi Phone Address 6 � S--i _ City, Contractors Name �-,r' — License R A�f" 1� Business Phone Contractor's Address �� —� iaA� Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO,ND WELL CHLORINATION ❑ WELL ABANDONMENT ❑. OTHER ❑ PUMP INSTALLATION 2d PUMP REPAIR REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 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 ❑ ItAXISTRIAL- P CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing . ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL ^-¢— Surface Seal Installed By: PUMP INSTALLATION: Contractor �fiP-•cam `� - — Type of Pump H.P. PUMP REPLACEMENT: P State Work Done , PUMP REPAIR: ❑ State Work Done T - DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material efld 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.. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued. 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California" Contractors hiring orsub-contracting signature certifies the following:"I certity that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 will ea orrout,lnspec on prior to grouting and a final Inspection. Signed X rTitle: EbL- ..c1/` Date, :'—�-- .(Draw Plot Plan on Reverse.Side) FOR DEPARTMENT USE ONLY PHASE 1 /JH'r� ��/ g� Date a • Application Accepted By . Additional Comments: Phase It Grout Inspection Pha incl Ion Inspection By Date _ Inspection By e Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE -❑ EACH ❑ January 1 Is Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE / B LESS PRORATION PLUS PENALTY OTHER OTHER 7$ Received by Date Receipt No. Permit N Iss a e ttslZe Mailed . Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Bot 2009 STOCKTON,CA 95201