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-PPI1CaT1oQJWIlle ProcessedsW ubmitted Properly Comp ted, BeSure To Sign The Application. FOR Or ICE ll�E: 'G ] `— N ,s ,982. APPLICATION _ZIV Jt) (For Non-Transferable, Revocable,Suspendable) t � AQU s `ACT►j DISTRICT HEALTH PERMIT PUMP&WELL y t (COMPLETE IN TRIPLICATE) ISTRICT 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 iso made S compliance with San Joaquih County O dlnancs'No 1862 and s. rules an r gulations of the San Joaquin Local Health District. Exact Site Address + ,p0 r Owner's Name ® /L � Q� City/Town - Address Phone �C�_,/�-- I Contractor's Name ` City 6_1 r Contractor's Address License# d Business Phone f Is Certificate of Workman's Compensation insurance on File With SJLHD? erg Yes Phone [ TYPE OF WORK (CHECK): NEW WELL V DEEPEN 13 Yes__ X_ No WELL CHLORINATION 13WELL ABARECONDITION 11 DESTRUCTION❑ J ABANDONMENT ❑ OTHER 13REPLACEMENT❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ DISTANCE TO NEAREST: Septic Tank � "— 't Sewer Lines Pit Privy Sewage Disposal Field f �Q Cesspool/Seepage Pit Other Property Line Private Domestic Well INTENDED USE Public Domestic Well ' TYPE OF WELL ,,❑ f OUSTRIAL ❑ CABLE TOOL V DOMESTIC/PRIVATE Dia. of Well Excavation 11DOMESTIC/PUBLIC ❑ DRILLED Dia. of Well Casing �y ❑ IRRIGATION �❑ RIVEN Gauge of Casing Vs CjRAVEL PACK Depth of Grout Seal El CATHODIC PROTECTION RRY 11DISPOSAL OTHER Type of Grout ❑ GEOPHYSICAL Other Information PUMP INSTALLATION: Contractor Surface Seal Installed By: PUMP REPLACEMENT: Type of Pump 13 State Work Done H.P, PUMP REPAIR: 1 ❑ State Work Done DESTRUCTION OF WELL. Well Diameter Describe Material and Procedure Approximate Depth M 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 orsub-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 wi call for a GrOulllnsppoon prior to grouting and a final insp/e/clio •i�. 4i Signed X 14a r w Plot Plan on Reverse Side) Date: � PHASE I FOR DEPARTMENT USE ONLY Application Accepted By � �r Additional Comments: Date Phase II r t nspection Inspection By to ,�� Phase III Final Inspection 1 �—L Inspection By r Date 6 _ ia^`Z,��-�, r Fee IS DUB: 11 ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED # EEE ` 3 AMOUNT _ N 4 LESS._:. � PRORATION PLUS i PENALTY OTHER OTHER Co Received by Date 'APPLICANTReceipt No. Permit No. Issuance Date 'APPLICANT-1 ALL COPIES TO: ENYfRONMENTAL HEALTH PERMIT/SEpVICES Mailed Delivered 1601 E:HAZELTON AVE.,P.O.Box 2009 - STOG1t:TON r_e aeon.