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F J+ Applications Will Be Processed When Submitted Properly Completed. a e pure I o algr Ric FF�OROFFICEUSE: APPLICATION For Non -Transferable, Revocable, Suspendable) PUMP & WELL 1 — ENVIRONMENTAL HEALTH PERMIT — COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health bistrict for a permit to construct and/or install the work herein described. This application Is made in compliance with San Joaq_ ui C unty O ante No. 62 the rules and re ulations of the San Juin Local Health District. 5-,:��:— City/Town Exact Site Address I - 1 ee-1. �% City— Owner's Name ;,., � j „� • �- � —1 Address L� Bu in ss P�pne — Contractor's Name _ License ` Emergency Phone —� Contractor's Address ---is' � No Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes TYPE OF WORK (CHECK). NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION ❑ PUMP REPAIF REPLACEMENT El LinePit Priv Sewer s � — y - DISTANCE TO NEAREST: Septic Tank -- — — Cesspool/Seepage Pit Other Sewage Disposal Field Property Line_ Private Domestic Well _ Public Domestic Well _ --- INTENDED USE ❑ INDUSTRIAL DOMESTIC/PRIVATE ❑ DOMESTIC/PUBLIC ❑ IRRIGATION ❑ CATHODIC PROTECTION ❑ DISPOSAL ❑ GEOPHYSICAL PUMP INSTALLATION: PUMP REPLACEMENT: PUMP REPAIR: = DESTRUCTION OF WELL: TYPE OF WELL ❑ CABLE TOOL Dia of Weil Excavation— — ❑ DRILLED Dia. of Well Casing -- -- ❑ DRIVEN Gauge of Casing --- - ❑ GRAVEL PACK Depth of Grout Seal— ❑ ROTARY Type of Grout ❑ OTHER r^- Other information -- Surface Seal Installed By: _ Contractor_ Type of Pump —T _ ` _ H.P. ❑ State Work Done LAP State Work Done �dr'- _ Approximate Depth Well Diameter--- — -- — Describe Material and Procedure the work will be done in accordance with San Joaquin County I hereby certify that I have prepared this application an a ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certilles the following: "I certify that in the performance of the work for which this permit is issued, I shalt 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 to workman's compensation laws of California." I will call for a Grout Inspeclion for to grouting and a linal inspection. "". ... ►- �'/ Title:.c - Dater 1 Signed X — (Draw Plot Plan on Reverse Slde) FOR DEPARTMENT USE ONLY PHASE 1Date j, — Application Accepted By Additional Comments _ --- - Ppase 111 Fin spection Phase 11 Grout Inspection _ `>��_� Date r inspection By Date Inspections" ❑ Jul t & Received By JWy 251Fee Is Due: 11 ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH El January 1 & Received By January 31 y REMIT —~ BILLING REMITTANCE S AMOUNT OUE CHECKED BASEI EXPLANATION DATE DATE REMITTF,D AMOUNT L FEE— LESS E£LESS PRORATION _ PLUS PENAL rY OTHER OTHER { _ 1 _ p y 1 Permit No ssuance ate Mailed Delivered Received_ by Date , Receipt Na APPLICANT—RETURN ALL COPIES TO_ ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. NAZELTON AVE., P.O. Box 2009 STOCKTON. CA 95201