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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION t (For Non-Transferable, Revocable, Suspendable) i ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY r 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 t made in compliance with an Joaquin County Ordinance No. iB42 and the rules d regulations of the San Joaquin Local Health District. f Exact Site Address � �-,�y-rr � City/Town ! c,[ Owner's Name _ �= j �r�,� Phone. Address 3 T� City Contractor's Name License01-Y2 Business Phone Contractor's Address �� -� rgency Phone __,T /I �r f — Is Certificate of Workman's Compensation Insurance on File With 'LH D? Yes No TYPE OF WORK (CHECK): NEW WELL}—!]EEPEN 0 9tRECONDIeTION D DESTRUCTIO,N,❑ d WELL CHLORINATION-[ —WELL.ABANDONMENT ❑ a OTHER O "'yi tlMP�II STA.LLATION Lr PUMP REPAIR nREPLACEMENT 4bd DISTANCE TO N{eE''AREST: Septic Tank Q/t Sewer Llhes0 Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL a f ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �]OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑,�. GR �EL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION 9?-19OTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Install By: 09Kv PUMP INSTALLATION: Contractor li Type of Pump H.P.— y, PUMP REPLRCEMENT: 13 State Work Done PUMP REP.AIR: El State Work Done ) t! DESTRUCTION OF WELL: Well Diameter Approximate Depth 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 "f. ris 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 (permit is issued, I shall employ persons subject to workman's compensation laws of California." I will cpbfor a Grout Inspection prior to grouting d a final inspection. Signed X _ _/ �`� ��C�, � Title: Dale: (Draw Plot Plan on Reverse Side) n FOR DEPARTMENT USE ONLY PHASE Application Accepted By � ^' y Date Additional_Comments:N k 41 is t"�.1, Ph a a II Gr ut-llnspection Phase III Final Inspection hh Inspection By Q Date /U , S Tia Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 4J PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 _E REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS a PENALTY k OTHER OTHER —79—dog 3_... '_71 � Received by Date Receipt No - Permit No Issuance Date Mailed Delivered - _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E./ T�TJJ AVE/�—.lBios-20 1 1 , CA