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V ,.Yt.....mwna ., .,.. ..,...�,�.,. ....� , .......un m.. vYm.r ...........— I` FOR r'FFICE USE: APPLICATION ` ;For Non-Transferable. Revocable, Suspendabil _ PUMP 3 V✓ELL ENVIRONMENTAL HEALTH PERMIT L(C .NPLETE IN TRIPLICATE) WATER QUALITY A.LJIIcaGOn 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 County Ordinance No 1862 and the rules and regulations of the Sa Jwoaagruuiin�--Local Health District. Exact Site Address �-L� �"t`TOy--•/ !' City/Town Owner's Name �f . ��.t� Phone I_s, __ Address _2C�/.s '�'t&,e IV � ,/ '1 City 41 5C%a Q ep Contractor's Name y� AvIrm dr 12Ru.G/1V*Se t3Y7-76z Business Phone_ - ZS" `Contractor's Address 'd __1r!�/C�e rgency Phone /�'!'h _ Is Certificate of Workman's CompensationIns ranee on File With SJLHD? Yes_ No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION CI DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONX PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 7 V 7 Sewer Lines �� Pit Privy 145 t l Sewage Disposal Field SA "}" CesspA/14- oo�ll/Se.epage Pit Alla— ,glhey Al ` 140— Property Line--U-.Q— Private Domestic Well �SedPublic Domestic Well /r' INTENDED USE TYPE OF WELL n^ 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation Id • �7 DOMESTIC/PRIVATE r❑ DRILLED Dia. of Well Casing Elp S _ DOMESTIC/PUBLIC �w DRIVEN Gauge of Casing 11 IRRIGATION Rr GRAVEL PACK Depth of Grout Seal CATHODIC PROTECTION XROTARY Type of Grout 0 DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: t4 177-&4 C r'C _PUMP INSTALLATION: Contractor ✓A!L- ' Type of Pump S " H.P. PUMP REPLACEMENT: ❑ State Work Done ?UMP REPAIR: ❑ State Work Done '-DESTRUCTION OF WELL: Well Diameter Approximate Depth .- Describe Material and Procedure y, 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 orlicensed 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 emp persons subject to work an's compensation laws of California." I will I for a Gr ind final inspec signed X -_��1jE� — Title: -,fy'aC - Date: , (Draw Plot Plan on Reverse Side) " FORD PARTME USE ONLY L,! PHASEI r q 7 Application Accepted By — -- - Date� Additional Comments. -- �} Phase 11 Grout Inspection _ -- Phase III FFinal�}nS°ection Inspection By yr�,4� Dat�,�-� "� Inspection By ' � ---_7 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT _ PER SITE 0 EACH ❑ January 1 8 Recelaed By January 31 ❑ July 1 8 Recervea 6y JOY 91 — "-- -'-_—_-- REMIT BASE ExPLAN?TION BILLING REMITTANCE 5 AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT _ _ -� � - -_-- l- fEE LESS 7 PRORATION -- PLUS PENALTY OTHER