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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) --- -- ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (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 Joaquin County OrdiLa2ce No. 1862 and the rules and regulations of the San Joaquin Local Health District. Enact Site Address *7.;a C7 F / b•p F� � Citylfown zt Owner's Name ' r \ -O :�, ( st H .Q S t:�y j Phone Address `7 �T'~ 'TAT City 4e ice.Ltt!\. ell . Contractor's Name 111 r�- Q• r aS" { S6 - License#/LYS ;2 E._1 Business Phone 7 'IJ -! 3 V 7 Contractor's Addrs6911 ?J�Q a f^ 7o r N5Jd : /Y-Emergency Phone 5-wM-- Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No TYPE OF WORK (CHECK): NEW WELLM— DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9'-� PUMP REPAIR❑ C REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank 1�� Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other C Property Line Z?_� Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL Gd'CABLE TOOL Dia. of Well Excavation ❑ ESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing `r ESTIC/PUBLIC ❑ DRIVEN Gauge of Casing IrL W11iRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal installed By: PUMP INSTALLATION: Contractor 511\,\a Type of Pump Zky b H.P. :?!Q PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure 1 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 laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. `l Signed X �� - 34% C _7_Q] Title: �\ --�\-.�� Dat L� - �{i ll Ll (Drew Plot Plan on Reverse Side) -�.. FOR EPARTM T USE ONLY (•�'+ ' 1 PHASE I t Application Accepted By Q Date C Additional Comments: r `� Phase II Grout Inspection Phase II final Inspa¢I'on Inspection By Date i t Inspection By v=% "�•' "-".L`a e _ i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ER SITE ❑ EACH ❑ January 18 Received By January 31 ❑ July 1 s Received By July 31 REMIT BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS -7 2 PENALTY J O OTHER OTHER Received by t card Receipt No. Perms o. I -- Issuance Data MaiNd DaNvared