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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign fie Application: FOR'OFFICE�USE: APPLICATION ' j r (For Non-Transferable, Revocable,Suspendable) J z 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 Co}nty Ordinance No. 1862 and the rules and regulations of the San J aquin Local Health District. Exact Site Address 1 �{S s /L/ �T 4e A74e,4 a&� /!� City/Town � &�Z2-2,0 i Owner's Name (gP O i-C Phone AddressCity f'» 42 9 Contractor's Name 1��' c I f vdtr(ie#",0,/g.E Business Phone 3 -� -7 Contractor's AddreSS�� IV, e mergency Phone Is Certificate of Workman's Compensation;Insurance on ile With S LHD? Yes No TYPE OF WORK (CHECK): :'NEW WELL DEEPEN ❑ RECONDITION 11DESTRUCTION❑ WELL CHLORI AT ON ❑ '-WELL ABANDONMENT 1:1 OTHER E] PUMP INSTALLATION PUMP REPAIR❑ f REPLACEMENT — w � DISTANCE TO NE REST'�- Septic Tank� 67 � Sewer Lines Pit Privy �11E1TJ� �1 t Sewage Disposal Fie _ e%7 e Cesspp000l//S�e�epage P �, it �4 /'7 e Other /1..� d Aj - Property LinelPrivate Domestic Well Public Domestic Well 161012 e- INTENDED USE TYPE OF WELL ❑ INDUSTRIAL .CABLE TOOL ,,r Dia. of Well Excavation DOMESTIC/PRIVATE C3DRILLED 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 ❑ GEOPHYSICAL / Surface Seal.installed By: _�J^ f' PUMP INSTALLATION: ontractor _el tl C� /,/JZ-l/ ea-/'/Z1 AJ 1�ype of Pump ?,A G~ l C ./ H.P. PUMP REPLACEMENT: Hyl © State Work Done PUMP REPAIR: ❑ State Work Done 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 Iawsof California." I vAlcallfora Grout spection rior to gro ting and a final inspection. „ µ Y,e Signed X �/� ,..Title: -CJYr. �^=Q--v :Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE t Application Accepted By ' ' y �1 Date ' �_A Additional Comments: 4&wt& Pha Grout In rection 9 �j Pha incl In ction '"�" inspection By ate /�``=-/ � Inspection By _. . ate 1 r, Fee Is Due: ❑ ANNUALLY ❑ PER UNI _ ❑ PER S1TE II-EACH ❑ January 1 &-Received By January 31 ❑ July 1 &Received By July 31 BILLING %'REAd1TTP.NCE $ REMIT BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT D FEE LESS C PRORATION PLUS PENALTY OTHER OTHER Received by Date I- Receipt No. Permit No. Issuance ate Mailed Delivered - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95201