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Applications Will Be Processed When Submitted Properly Completed. Be Sure To'Sign The Application FOROFFICEUSE: APPLICATION . (For Non-Transferable, Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WEI L -� (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 Joaguin,,�C,,ou/nty Ordinance No. 1862 and the-rules and regulations of the San Joaquin Loc l Health District. Exact Site Address-3331 C-1-40.OL I Rju r- City/Town � k� •.; Owner's Name 5_ r��c�l� WtivbgIR._ Phone Address df City A1JPd1Y Contractor's Name tL"K WELL d EQulp & -T - License# Z�Business Phone G=+-4 Z,3 Contractor's Address ?..QZ`�_ E. _0+PI'�i.;u-Is1I� Emergency Phone � Is Certificate of Workman's Compensation Insura a on File With SJLHD? Yes �r No TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ IU WELL CHLORINATION ❑ WELL ABANDONMENT❑ _ OTHER'❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ G } REPLACEMENT❑ i DISTANCE TO NEAREST: Septic Tank So �` Sewer Lines Pit Privy —~ j Sewage Disposal Field Cesspool/Seepage Pit Other Property Line /A!'rPrivate Domestic Well jM Public Domestic Well ""'--'� r INTENDED USE TYPE OF WELL l of F ❑ II V�RIAL 11CABLE TOOL Dia. of Well Excavation - l [�}/ `r. F DOMESTIC/PRIVATE ❑ DRILLED � Dia^of Well Casing �* ❑ DOMESTIC/PLBLIC ❑-DRIVEN - = ^ I Gauge-of-Casirlg y ❑ IRRIGATION ❑� GRl PACK Depth of Grout Seal 1:1CATHODIC PROTECTION LS OTARY Type of Grout TW i ❑ DISPOSAL I ❑ OTHER Other Information i V ❑ GEOPHYSICAL :- Surface Seal Installed By: z r PUMP INSTALLATION: Contractor Type of Pump . ' H.P. PUMP REPLACEMENT: ❑ State Work Done ''- _ PUMP REPAIR: State Work Dane k DESTRUCTION-OP WELL:------- -=Well Diameter------ - — - - =-S Approximate Depth r # = Describe Material and Proceourew =• y 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. Homb'Oilvner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this,permit is issued, l 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 fo workman's compensation laws of California." ' v `. { g twill calf f rout Inspection prior r�r uNng,and a final inspec ion. _ / jFL '� '_ Signed X � .v>~divar ,� � Title:�� Date:.fa � I k (Draw Plot Plan on Reverse Side) FOR DEPART ENT USE ONLY PHASE Application Accepted'By""_-,r Date " Additional Comments:-F Phasa II Grout Inspection Ph a Itl Final Inspection/ Inspection}By F 1 2G �T_ Date 4rt$1 ;f+ Inspection By ` Date $'i f Z u Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 § REMIT BILLING REMITTANCE $ BASE EXPLANATION PATE DATE REMITTED AMOUNT DA CHECKED t ;AMOUNT FEE ...�,......- ...-,�.y....._sem_:..- „...-.,-Y.rw-+- .,",�....._-.sem.........-. _.`...•¢.�—....,.;;F'-�...--w..-.�.. PRORATION f PLUS " < PENALTY OTHER �. OTHER Y It I751 Recesvetl-dye Date Receipt No.,, .Permit No. Issuance Dale Mailetl (`''6/-Delivered'. APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 20TOCKT",_CA."n /