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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made tothe San Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is made in compliance with San Joaquin. ot�1 ty r inance No. 1862 and the rules and regulations of the San Joaquin Local Health District, Exact Site Address N1.0s. City/Town Owner's Name ( 0 V!/fTf -Sty-C))n?,_1{ 3, t f-) Phone � n F Address 1�),r�. 1�� I l 101-y Z�l�i "� ��' city,.V` Q ` ' " A _f)•`�`' l r I) i^ License ss Phone# > Business u Contractor's Name _ Contractor's Address zf r ��V -0'21 C r•_ 1 Emergency Phone "j l Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes V No TYPE OF WORK (CHECK): NEW WELL I_ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ 1 1 DISTANCE TO NEAREST: Septic Tank flu '� Sewer Lines Pit Privy 11 Sewage Disposal Field Cesspool/Seepage Pit Other _ r Property Line Private Domestic Well 'Public Domestic Well INTENDED USE I TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �� f r1 El--DOMESTIC/PRIVATE ❑'DRILLED Dia. of Well Casing jn ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 11W) rfJ O U ❑ IRRIGATION M—GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ffin-�n n) r ci ❑ DISPOSAL OTHER Other Information Mai ' bo 7 ray ❑ GEOPHYSICAL Surface Seal-Installed By: HLI Y6n Y`4as PUMP INSTALLATION: Contractor ',Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done N PUMP REPAIR: ❑ State Work DoneO 4 DESTRUCTION OF WELL: Well Diameter -Approximate Depth {{[ Describe Material and Procedure ++ , r s J 1 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 following:"I certify that in the performance of the work forwhich this i permit is issued, I shall employ persons subject to workman's compensation laws of California. ,A I will tali for a Grout Inspection prior to grouting and a.final inspection. a Signed X ) .J I.�✓? ( 1 � i,r! � .� Title: Date: r (Draw Plot Plan on Reverse Side) E R � -FOR DEPARTMENT USE ONLY PHASE I Application Accepted By (Date t. Additional Comments:�Za��ti�� s..t��`�� = N .L�-^�. `r''"'•-� , P ase rout Inspections y Phase III Final Inspection + '� Inspection By DateInspection'By Date Fee Is Due: ❑ ANNUALLY PER UNIT PER SiT �CH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT ' BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED Atb10UNT DUE CHECKED _.AMOUNT i •QlJ € FEE LESS " PRORATION PLUS PENALTY r OTHER OTHER - � �� Received•by - ate „Receipt N -'TPermitNo. _ 'Issuance Date - - Mailed Delivered- ♦.... - �� } ' APPLICANT''RET��ALL COPIES TO:��ENVIRONMENTAL HEALTH PERMIT/SERVICES - " 1601 E'.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 9520"��'� a. j -