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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) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (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 Joaquin County Ordinance No. 1862 and the.rules_ar regulations' f�the San Joaquin...Local.Health District. �,CL/19TT AP019D 4WIDg-W 0I/a e �c�('City/Town N; ac.EFor�l Exact Site Address P. Owner's Name �%r �' —�sr�, GG>t ,t:- �Piv Phone -228/ Address lgfy �' ��/ o 2 due. _ � City StrCE rs Contractor's Name Q AA License# 9/OS' Business Phonej q/j ) Contractor's Addressr�c �s�.yfo Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X ._. No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONOC WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ l DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information X GEOPHYSICAL Surface Seal Installed By: . PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter -3 4 Approximate Depth Describe Material and Procedure a 4;llop ",;W Cce2crezCe (] t 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 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 call f a Grou Inspe ' n prior to grouting and a final inspection. `�I Signed X Title: �' Sfrrr rd-'t Date: 4 �`85� (Draw Plot Plan on Reverse Side) � _101- —.0� FOR DEPARTMENT USE ONLY /!Yl PHASE I Application Accepted By Date Additional Comments: Phase 11 Grout Inspection ' PharLe III Final Inspection Inspection By hate Insperjtion By e Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BILLING REMITTANCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER X35 3qZ �-1Fs-mss Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITYSERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,GA 95201