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Applications Will Be.Processed When Submitted Properly Compimea. ae Jure rw�y. ••� ^rr APPLICATION F(CE USE: g (For Non-Transferable, Revocable, Suspendable) PUMP&WELL - '� ENVIRONMENTAL HEALTH PERMIT (COMPLETE iN TRIPLICATE) �p"�� , �-r� � ' WATER QUALITY d 6 3 R f R0r Z� Application is hereby madetotl>eSanJoaquinLocalHealthDistrictforapermittoconstructad/orinstalithework herein described.This application is made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. ity/Town h� Exact Site Address I� ! D r _ Phone - Owner's Name 7. City M Address � �6)q Z.8usiness Phone �7Q[[Lf/I«CT Contractor's Name _ � W License# 5 Emergency Phone Contractor's Address No Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes TYPE OF WORK (CHECK): NEW WELL❑ DE ❑❑ OTHERCO❑ ITION�A�DESTRUCTION UMP INSTALLATION 13 PUMP REPAIR❑ .WELL CHLORINATION 13 WELL ABANDONMENT REPLACEMENT❑ es LinPit Privy DISTANCE TO NEAREST: Septic Tank Sewer Cesspool/Seepage Pit •^�---"� Otff'�- Sewage Disposal Field y Property Line Private Domestic Well 77=7—Public Domestic Weir INTENDED USE TYPE OF WELL X 4 11 INDUSTRIAL CABLE TOOL Dia. of Well Excavation 1' Dia. of Well Casing C3DOMESTIC/PRIVATE s ❑ DRILLED Gauge of Casing 13 DOME! 13 DRIVEN 11` GRAVEL PACK Depth of Grout Seal IRRIGATION ❑ Type of Grout CATHODIC PROTECTION , ❑ ROTARY ❑ DISPOSAL ❑ OTHER Other information I ❑ GEOPHYSICRL G Surface Seal Installed By: Op tor R r O Contractor PUMP INSTALLATION: H.P. Type of Pump PUMP REPLACEMENT: ❑ State Work Done — PUMP REPAIR: ❑ State Work Done - Diameter Approximate Depth DESTRUCTION OF WELL: Well Qiame ` � I Describe Material and Procedure �. have prepared this application and that the work will be done in accordance with San Joaquin County I hereby certifythat I pre - . P ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"l certify that in the performance of the work for which this permit 4 l + is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." l i Contractor's hiring or sub-contracting signature certifies the following:"l 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 c I for arou Grout Inspection nor to grouting and a final inspection. s I Date: k T Title: ".. Signed X (Draw Plot Plan on Reverse Side) j FOR DEPARTMENT USE ONLY PHASE I Date y` Application Accepted By w _ Additional Comments: w Y - Ph a a Ill Final Inspection Ph ase II Grout Inspection t 2 k Inspection ByPry Date inspection B Fee IS Due: Cl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31/ ❑ July 1 &ReceivedREMITuly 31 BILLING REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT I FEE e 1 LESS 111 PRORATION t PLUS PENALTY OTHER I OTHER i v Date Receipt No. Permit No. Issuanc Date Mailed D livered' Received byENVIRONMENTAL HEALTH PERMITlSERYICES 4601 E.µAZELTON AVE.,AYE.,P.O-Bo=2009 STOCKTON,CA 95201 APPLICANT—RETURN ALL COPIES TO: