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It, II- .A J L- t Applications Will Be Prosed When Submitted Properly Co �eckb sfu�flr5ign The Aq�tion. OR JrFICE USE: APPLICATIO 4 (For Non-Transferable, Revocable, ndablplf 1519 H PUMMPP&WELi..— ENVIRONMENTAL HEALTH PERMIT l t L;'?L (Jill WATER QUALITY SAN 11,) �c �tj(Kiv� (COMPLETE IN TRIPLICATE) y,.{ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/lAFak, TNe work herein described.This application is made in compliance with San Joaquin Cqunty QI>iinance No. 1862 and the rYles and regulations of the San Joaquin Local Health District. Exact Site Address le 1 ry LC �LI HvG( City/Town --AL2-jC"�� ! 7 Owner's Name - Phone Address -f�r-- - r_ -, t221 City u License p Business Phone '/-S2 /n Contractor's Name - Contractor's Address { / `- `✓'- Emergency Phone _ - Is Certificate of Workman's Compensation Insur nce on FileWithSJLHO? Yes 1i No �� TYPE OF WORK (CHECK): NEW WELL❑ DEEPE� RECONDITION 11 DESTRUCTION❑ WELL CHLORINATION 11 WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR a REPLACEMENT❑ /T- / DISTANCE TO NEAREST: Septic Tank I it Sewer Lines ' L �1iy G7 Pit Privy, o1 Sewage Dispo I Field Cessp oV/Seepage Pit % Oth r N Property Line-�.- Private Domestic Well/)-,�F G (Public D mastic Well f INTENDED USE TYPE OF WELL ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation ArY1�h-`;: ❑ DOMESTIC/PRIVATE Y9 DRILLED 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 - 0 ❑ GEOPHYSICAL Surface Seal Installed ByL'Qlll1 PUMP INSTALLATION: Contractor ✓ 21 J <" Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 1 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 istrict.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 laws of California." I wi all fol a Grout Inspection prior to grouting and a final Inspection. Signed f- Title: �1 �� c-� Date: �w Plot Plan on Reve se Side) R DEPARTMENT USE ONLY PHASE I �O Application Accepted By Date Additional Comments: Phase II Prout InspQec�ti�onI /!.v '"- Phase 111)Final Inspection Inspection By�1 h. L �^ r I speclion.By fQ- tP�U_a„D„�P, ` Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT OrPER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 8 Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED D E DATE REMITTED AMOUNT FEE wt LESS PRORATION PLUS PENALTY , OTHER OTHER Received by Date Rece,Pt No Permit No Issuance Date Mallet] Delbered '•^c ^