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4' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.T a1 FrOR OFP_cE 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 permitto construct and/or install the work herein described.This application is made in compliance with San Joaquin Co ty Ordinance No. /7�62 nd the rules and regulations of the San J quin Local Health District. Exact Site Address J Q a-I►/' / Pk City/Town �'C_a Owner's Name C` C -u 1 b-P.rt-S o rel Phone 36 a -0 f a Address 3 y/ /L/, City b n w k Contractor's Name ut v r/i G ��f� [�,, � cense# ��) 23 Business Phone -3 b Contractor's Address"2 ni©,0d /��• �y L �� qIf ?g Vy Phone /L J v tv-Q-_ 1 Is Certificate of Workman's Compensation Insur4rice on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL, r DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑, "WELL,ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR El REPLACEMENT❑ f DISTANCE TO NEAREST: Septic Tank 1640-r--74- Sewer Lines Pit Priv��j`'� Sewage Disposal F�ifie�+ld Cesspool/Seepage Pit Other Property Line—Private Domestic WellAA/-e- Public Domestic Well e/v INTENDED USE TYPE OF WELL " © INDUSTRIAL ABLE TOOL Dia. of Well Excavation _ `f OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing x ` ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION f. ❑ ROTARY Type of Grout e m e n-r © DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL x Surface Seal Inst ed By: PUMP INSTALLATION: Contractor u e/1,G Type of Pump _S_&_4>- H.P. PUMP REPLACEMENT: ❑ State Work Done � C PUMP REPAIR: ❑ State Work Done- "` `� �-• x 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 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 All call for a Grout,IgVeclion pri r to groutind a final inspection. Signed X . _— Title: — Date:. (Draw Plot Plan on Reverse Side) y FOR DEPARTMENT USE ONLY - PHASE I Application Accepted By Date 81 Additional Comments: h s 11 Grout Inspection III Final Inspection Inspection 8 Dat Inspection By Dater u Fee IS Due: ❑ ANNUALLY ❑ PER UM T L❑ PE SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ REMIT AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT LESS PRORATION PLUS r - r PENALTY _ „�, 4 OTHER OTHER D-Z lI ��, y� Received by ate Receipt No- Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 TO.KT.N,CA 95201