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r x .,–,v-- Applications ,y..Applications Will Be Processed When Submitted Properly o APPLICATION FOR OFFICE USE: y ��j (For Non-Transferable, Revocable, 5uspendable) pUMp&WELL ( ENVIRONMENTAL HEALTH PERMIT y WATER QUALITY (COMPLETE IN TRIPLICATE) ittoconstruct Application is hereby made to the San Joaquin Local Health Dis�ictfor aperil rules and egulations oftthe San Joaquin lnL�ocal HealthTDi[his District. is Q made in compliance S J a oundinance No. City/Town > Cy 4d Exact Site Address f $' Phone Owner's Name City J Address vpp� /License Business Phone D Contractor's Name i Emergency Phone k Contractor's Address � �f No ` Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes TYPE OF WORK (CHECK): NEW WELL W`__DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ t WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 12�—PUMP REPAIR❑ REPLACEMENT❑ f' _7=77— Pit Privy { Sewer Lines �� DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other Sewage Disposal Field�D�"" Property Line-7==— Private Dome�c Well �Q// Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation S �r ❑ DRILLED Dia. of Well Casing . DOMESTIC/PRIVATE 11 DRIVEN Gauge of Casing 13DOMESTIC/PUBLIC Depth of Grout Seal ❑ GRAVEL PACK p � ❑ IRRIGATION �1L fd CC3 N� . ROTARY Type of Grout .X ROTARY 11 CATHODIC PROTECTION r' ❑ DISPOSAL 13 OTHER Other Information Surface Seal Installed By: AC + ❑ GEOPHYSICAL PUMP INSTALLATION: Contracto Type of Pump pl/I/ /•2 S H.P. ? PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure he work will be done in accordance with San Joaquin County 1 hereby certify that I have prepared this application and that f ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work lorwhich this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." ure certifies the following:"I certify that in the performance of the work for which this Contractor's hiring or sub-contracting signet permit is issued, I shall employ persons subject to workman's compensation laws of California.' i will call for a Gro It p do rio to grouting and a final inspection. f Title: C~Dr�� r Date: (Draw Plot Plan on Reverse Side) I , j FOR DEPARTMENT USE ONLY PHASE Ir Date Application Accepted By Additional Comments: p as 11 final Inspection a II Grout Inspection Inspection By Date Inspection By Date IPER UNIT ❑ PER SITE ❑-EACH ❑ January 1 &Received By January'31 ElJuiy 1 &Received By July 31 Fee Is Due: ❑ ANNUALLY ❑ REMIT - a BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION PATE DATE REMITTED AMOUNT FEE LESS PRORATION I PLUS PENALTY I OTHER (- OTHER i. - �7 Received by Date Receipt No, 1601 E.HAZELTON AVE.,P•.O..Sox 2009 SOON,CA 95201 Permit No. Issuance Date Mailed Delivered ,APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTALHEALTHPERMIT/SERVICES �.