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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. -*•- — 1=OR O1-€ICE USE: - APPLICATION - (For Non-Transferable, Revocable, Suspendabie) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT _ co COMPLETE IN TRIPLICATE / ( ) �� _/j�TATER QUALITY � r Application is hereby made tot q in oc I a1 h istrict fora permit to construct and/or install the work herein described.This application is J made in compliance with San Joaqui_County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, i Exact Site Address 0 City/Townn Owner's Name : L/r Phone Address �_ �+ City Contractor's Name License#-3736t,4'71 Business Phone J�_�U Contractor's Address l'�7 {& - Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X— No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy l Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well fINTENDED USE TYPE OF WELL G1 I ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation .DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing , e ❑ DOMESTIC/PUBLIC i DRIVEN Gauge of Casing ❑ IRRIGATION # 11 GRAVEL PACK Depth of Grout Seal: - ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ ❑ DISPOSAL ) ❑ OTHER Other Information I ❑ GEOPHYSICAL j Surface Seal Installed By: PUMP INSTALLATION: I Contractor .�o� � ��o-� I Type of Pump -cc-t;— H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: i ❑ State Work Done ' DESTRUCTION OF WELL: 1 Well Diameter Approximate Depth Describe Material and Procedure Utom.— •_"� I hereby certify thaVI have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,' -1state aws, 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 ofthe work forwhich this permit ,is issued, I shall not employ any person in such manner as to become subject to work6an's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employlpersons subject to workman's compensation laws of CAlifornia." I w' a Grout In ection prior to grouting and a final inspection. f Signed - Title: ��r x�t�+� 3 Date: i (Draw Plot Plan on Reverse Side) fj FOR DEPARTMENT USE ONLY t PHASE I Application Accepted By Qpin a,6 '' '` "�'"^.'"-Date z 'Pd Additional Comments: i }{ 3 ''- Phase II Grout Inspection , ` Phase 11 Final Inspection Inspection By Date Inspection By Date Z�13)9 I Fee Is Due: ❑ ANNUALuY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 f e BILLING REM#TTANCE $ REMIT 4 BASE EXPLANATION AMOUNT DUE CHECKED I[r DATE DATE REMITTED AMOUNT FEE LESS PRORATION ' PLUS PENALTY � l OTHER OTHER S i Received by - Date 3 Receipt No, Permit o. Issuance Date Mailed, Dell red:(^_ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009_lesTOCKTON1 At9i2A'I mer' rCrr !!!