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Applications will lie Hrocessea when suomntea vropeny uompietea.tie sure to sign The Application. FFOEROTFFICEUSE: 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 for a permit to construct and/or install the work herein described.This application is made in compliance with San Joraa uir//County Ordinaa/�nn/cce NY. 1562/a�}d the rules and regulations of the San Joaqui Local Health District. Exact Site Address .22 e 46 /'�`/�/ „� City/Town XA1 Owner's Name an/ GGJeLEf Phon Address /4 City_ p etOS �J ��S Contractor's Name to License#733//(4 Business Phone g!y/7T-..2k/6 tr Contractor's Address - Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—� No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11DESTRUCTION❑ WELL CHLORINATION ❑ WECLABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank r Lines 7(w -f Pit Privy Sewage Disposal Fields Cesspool/Seepage Pit Other _. lea, Property Line Private Domestic Well 1�/k— Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL kCABLE TOOL Dia. of Well Excavation f Z 6.11 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing y _ - ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casingz/J aTQL (Jett 1r IXIRRIGATION ❑ GRAVEL PACK Depth of Grout Seal L; ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout N Ir❑ DISPOSAL ❑ OTHER Other Information p) ❑ GEOPHYSICAL Surface Seal Installed By: All JAIZ E PUMP INSTALLATION: Contractor r t. Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done 3 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." Gee Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued. I shall employ pers ns subject to workman's compensation laws of California." I will call for a7Gr In ectio or to grouting and a final Inspection. ^� ,y/ t Signed X � Title: 4m�7L Date: �.5 /C/.JC. ,/ eo (Draw Plot Plan on Reversejide) n FOR DEPARTMENT USE ONLY PHASE Application Accepted By /V"5'tJ'f`r'.','F /yy��/ -- _ Date 3k/ffO Additional Comments: Phase If Grout Inspectionh III Final Inspection Inspection By Date coon Insp By 1 Date A Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July t d Received By July 31 BREMIT BILLING REMITTANCE s BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY _ OTHER OTHER _ � S Received by Date Receipt No, Permit No. 1 uance Date Mailed Delivered