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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION f (For Non-Transferable, Revocable, Suspendable) ` ENVIRONMENTAL HEALTH PERMIT PUMP&WELL j (COMPLETE IN TRIPLICATE) WATER QUALITY � 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 Joa uin Count O.rdinan o. 1862 and t rules and regulations of the San Jo in Local Health District. Exact Site Address�7 W /_ DM 0\;_�� City/Town F`S ! tP06C. C.Q-. t Owner's Name _ \ (J /VM 1 S D /1l Phone Address - 6A,- City oAr— C Contractor's Name MaA VJ{V icense#3�Q Business Phone S�( ]- (5 Contractor's Address �g��r-6L1Qtd. Emergency Phone �� — a 3 9 7� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yesy No TYPE OF WORK (CHECK): NEW WELL 2� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 'PUMP REPAIR❑ REPLACEMENT❑ I DISTANCE TO NEAREST: Septic Tank S1wer Lines Pit Privy Sewage Disposal Field ^�3 A Cesspool/Seepage Pit --^ Other I Property Line --r Private Domestic Welles Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL 1 Dia. of Well Excavation ❑D MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION 0-11 TARY Type of Grout G1Ir f o b/'7t Co trC_. E ❑'DISPOSAL ❑ OTHER Other Information -_5.4 f�Q =01 � ❑ GEOPHYSICAL rface Sea Installed By:,- PUMP INSTALLATION: Contractor d- 1. C� Type of Pump v H.P, PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter 1 Approximate Depth i 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 signature certifies 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 foltoWing:"I certify that in the performance of the work forwhich this y permit is issued, I shall emplo rsons subject to workman's compensation laws of California." + will call for a Grou Ins n rill to grouting and a final inspection. Signed } Title: C�c-y'(`�fl r Dale117- 3 (Draw Plot Plan on Reverse'Side) FOR DEPARTM NT USE ONLY j PHASE i p �+ Application Accepted By Date Additional Comments: Phaseill Grout Inspection Phase Ill Final Inspection Inspection By. Date Inspection-By Date �vf i Fee Is Due: El ANNUALLY ❑ PER UNIT t]7 PER SITE ❑ EACH ❑ January 1 S Received By January 31 [] July 1 S Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED J� AMOUNT gT I Z .FEE LESS PRORATION PLUS PENALTY OTHER I OTHER Received by Date Receipt No Permit No. /issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA