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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The� Application., FOR OFFICE USE: APPLICATION `G I �p• l7A Non-Transferable,Revocable,Suspendable) ) PUMP&WELL ENVIRONMENTAL HEALTH HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATERQUALITY l Appl ication is hereby made to the San Joaquin Local Health District for a permit to construct end/or install the work herei n described.Th is application is made in compliance with San Joaquin CountOrdinance No. 1862 and=the rules and regulations of the Sen Joaquin Local Health District. y Exact Site Address �i� O �_�� d.a- Cit /Town Owners 42Z Phone � � " Address - City. Contractor's Name cQ fie — License rk�(7 I Business Phone — Contractor's Address Emergency Phone r�In Is Certificate of Workman's ompensation Insurance on File With SJLHD? Yes No v 1 TYPE OF WORK (CHECK): NEW WELL DEEPEN C1. RECONDITION❑ DESTRUCTION❑ ad WELL El 'WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION M---PUMP REPAIR❑ 66 REPLACEMENT❑ DISTANCE TO NEAREST: 'Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Lina Private Domestic Well Public Domestic Well _} INTENDED USE TYPE OF WELL -r\ ❑ IN9_USTRIAL ❑ CABLE TOOL Dia. of Well Excavation TIC/PRIVATE ❑ DRILLED Die. of Well Casing ❑ DOMESTIC/PUBLIC Q DRIVEN. Gauge of Casing ❑ IRRIGATION Q GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL Q OTHER Other Information ' ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: por)trector _�f Ol�A Type of Pump *'. H.P. PUMP REPLACEMENT: .❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: :Well Diameter Approximate Depth d' Describe Material and Procedure hereby certify that I have prepared this application and.lhat 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." 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 shall employ persons subject to4orkman's compensation laws of California." 1 He a Grout blsp ction prior to grouting and a final Inspection. Signed Q�l Title' um�ne=� Date: ' (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE 1 Application Accepted By Date Additional Comments: Phase 11 Grout inspection ha I al Inspection, Inspection By Date _ Inspection By Date 5 Fee IS Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1&-Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED �aDATE DATE REMITTED AMOUNT FEE VT, 5 LESS5 PRORATION PLUS PENALTY OTHERI OTHER 7 � Received by Dale Receipt No. Permit No. Inuane Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 12009 STOCKTON,CA 95201