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FOR OFFICE USE: APPLICATION 'or Non-Transferable, Revocable,Suspendable)� PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (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 oaquin County Ordinance No. 1862 and the rules and regulations of the San oaq in Local Health District. Exact Site Address r��27� h//oirc Grotic. 90 City/Town Owner's Name oetr-_57 e J/ A V,4S Phone �` Address /CU13 RIIAer /2 , City A a s7n Contractor's Name CILARIC IVEUF Fv(jjp. CO. ,25!c License p Business Phone 4612- Contractor's G12'Contractors Address 20 24 E1 CAe.17tP WA III Emergency Phone /Va Ale, Is Certificate of Workman's Compensationinsu nce on File With SJLHD7 Yes No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Ct WELL CHLORINATION 11 WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION 11 PUMP REPAIR � REPLACEMENT❑ NOT � /J'r/NG .4r ?wAr 71NF DISTANCE TO NEAREST: Septic Tank ") G� `.n Sewer Lines + Ga Pit Priv iii X1,14- 3 Sewage Disposal Field f- oy Cesspool/Seepage Pit AV AJ� Other Property Line yS " Private Domestic Well'f 3f7� r Public Domestic Well fs INTENDED USE TYPE OF WELL /� r/® N \7 19 � ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing SCi ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �2 57FEL E ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ROTARY Type of Grout ' ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor WEY.L E"OU1P GO t te�'- Type of Pump SW B e H.P. PUMP REPLACEMENT: ❑ 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. Home owner 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 will all for a Gro tlnspectiO prior to grouting and a final Inspection. !! Signed X d�� , Title: Date: (,—AV /175 (Draw Plot Plan on Reverse Side) FOR DE ARTMENT USE ONLY PHASE Application Accepted By Date 7t Additional Comments: Phase 11 Grout Inspection - Phase 111 Fina tion Inspection By �' �' Date 9' �� Inspection By Date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE (/ LESS PRORATION PLUS PENALTY OTHER OTHER _ 6 Received.by Date Receipt No. Permit No. isayarceluate Malled Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Boa 20011 STOCK,PN,CA 707