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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION 6 -- — Non-Transterable,Revocable, Suspendable) PUMP$WELL ENVIRONMENTAL HEALTH PERMIT �_ [ (COMPLETE IN TRIPLICATE) WATER QUALITY c 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. 1862 and the rules and regulations of the Sant oaquin Local Health District. Exact Site Address ��"� I City/Town Owner's Name PhoneZ-- Address ! mac. S City s _ Contractor's Name —4�p � ¢ ��-� License lL� 1 Business Phone '��/ 1 Contractor's Address 4_(n " - Emergency Phone _ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No O TYPE OF WORK (CHECK): NEW WELL f] DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®—UMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank �_ Sewer Lines Pit Privy Sewage Disposal Field - Cesspool/Seepage Pit Other y' Property Line Private Domestic Well Public Domestic Well n INTENDED USE TYPE OF WELL ❑ IND STRIAE ❑ CABLE TOOL Dia.of Well Excavation © OM ESTIC/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 IJ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surtace Seel Installed By: PUMP INSTALLATION: Contractor Type of Pump �d H.P.J Qom' PUMP REPLACEMENT: 11State Work Done17 PUMP REPAIR: 0 State Work Done `{bJ 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. Homeowner or licensed agent's signaturecertifies 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." Contractor's hiring or sub-contracting signature certifies the lollowing:"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 e r kGrout Inspection prior to grouting and a final Inspection. Signed X `� 7ltle .T Ate. W-�_ Date: (Draw Plot Plan on Reverse Side) . ' FOR DEPARTMENT USE ONLY PHASE I Application Accepted By Date Additional Comments:, Phase It Grout Inspection h III Final Inspection/ Inspection By Date Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE `,� 47 `4S—*o LESS PRORATION PLUS t PENALTY OTHER OTHER Receneo by Date Receipt No. Permit No. luuance ate Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 164111 E.HAZELTON AVE,P.O.60.2009 STOCKTON.CA 9S201