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Applications Will Be Processed When Submitted Properly Completed.9e Sure To Sle Appl cat ,u FOR OFFICE USE: APPLICATION rn U (For Non-Transferable, Revocable,Suspendabte) MAR ;) qqpp„ ENVIRONMENTAL HEALTH PERMIT SAN PUMP UdELL OMPLETE IN,TRIPLICATE)^ /.I �CAQUIIV WATER QUALITY EALTy DlCC7 LpQnL+A` Application is hereby madeto theSen Joaquin Local Health District fora permittoconstruct and/or install the work herein describe?THi9a�plicetion is made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address Z9 g,5 Lows IS /1-r� City/Town Owner's Name _ -4t'f��►!S 7444- vs sGf- Phone Address 8S C_0'3 � _ City Contractor's Name License'<3 �9gusi as Phone Contractor's Address Emergency Phone fS/— 7— Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK(CHECK): NEW WELL El DEEPEN 13 RECONDITION❑ DESTRUCTION❑ _1 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ ' PUMP REPAID REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines . Pit Privy Sewage Disposal Field - - -Cesspool/Seepage.Pit�—.Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ 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 Q❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: �CState Work Done J / DESTRUCTION OF WELL: Well Diameter Approximate Depth .. Describe Material and Procedure Ihereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County �r 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 forwhich thispermit 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 issued, 1 shall employ p subject to workman's compensation laws o1 California." I w 1 a Grout Inspects pr' o grouting and a final inspect n. 111 Signed X - ,v- Title: (Draw Plot Plan on Reverse Sid —�^ FOR DEPARTMENT USE ONLY PHASE] Application Accepted By _. _. Date 3- 7—P2;- Additional —P1Additional Comments: Phase 11 Grout Inspection — -- Phase 1 ]nal 1 ectl n Inspection B Inspection By Y Date �9� - y-pi I Fee Is Dae: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i It Received By January 31 ❑ July 1 S Received By July 31 F BILLING REMITTANCE 5 REMIT .1t BASE EXPLANATION OATS GATE REMITTED AMOUNT DUE' CHECKED AMOUNT FEE A.S. pp e LESS PRORATION PLUS - PENALTY OTHER S O OTHER ' -v �ncs �SrZZR' I y Re I ed by Dale Rece,Dt ND. Pommt No. Issuance Date Misled Delivered �,..r- 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMEWT NEALTN PERMIT/SERVICES 1p1 E.NA2EL70N AVIL,P.O.am axa BTOCNTON:-.0 Pa,W / i.:a V- 7