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Ft.. USE-] 1j�..Dl ;I ' APPLICATION (For Nun-Transferable, Revocable, Suspendablej PUMP& WELL ENVIRONMENTAL HEALTH PERMIT r ;COMPLETE IN TRIPLICATE) WATER QUALITY -r application is hereby made to the San.loaquin Local Health District fora permit to construct and/or install the work herein described. This applicatir rn is made in compliance with San Joaquin CoAnly Or irrance No. 1862 and the rules and regulations of the San Joaquin Local Health District. exact Site AddressLf I _._ City/Town /�li�Cc C _ C 'r Owner's Name ,�.V, ��. '. ' Phone lF3_51__2_"_11?.. _ PQ Address City z7k� 'contractor's Name _ o cense#;5 - Business Phone ,..,contractor's Address _._____ Emergency Phone -_-. T� '�� _ —_ W Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No v� iTYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONY DESTRUCTION❑ NELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 ''REPLACEMENT,c 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 13 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ,❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY T' ype of Grout —0 DISPOSAL ❑ OTHER _ Other Information ❑ GEOPHYSICAL Surface Seal Installed By: _— PUMP INSTALLATION: Contractor Type of Pump H.P. --..__. ._...0 PUMP REPLACEMENT: 5LState Work Done 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 Ll/� 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 forwhich 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I Will 11 for a Grout Inspection prior-lo touting and a final InspecooD._ ' 1 Signed X ' Title: . Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI Application Accepted By _ _. ._ Date Additional Comments: Phase II Grout Inspection Ph se I Final Inspectionff Inspection By __._.._ Date Inspection By k.� Date _1 -?-Op I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Q Received By January 31 ❑ July 1 d Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No hermit No. Issuance Date Mailed Delivered .ee „-.tet ..�...�..... .......��... �....,...,....�.._.. .,�.,.,...�_...-,__.....,...., .__._ ...--'--.. ..� -- - ---- ----.__.. -. --_-.