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Appllcalions Will de Processed When Submitted Properly Completed.Be Sure To Sign The Application. FF`QR_OFFI_CE USE: APPLICATION --- - � (For Non-Trans:erablle,Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT r (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Healt h Oistrict fora permit to construct arid/or install the work herein described.This application is i made in compliance wrtflh_San #Joaquin Count Ordinance NNc�1862( nd the ruses and re ulati[m bf the San Joaquir,,Local Health District. Exact Site AddressiL-!�{.L� �>_!.`IZ.L'r12>1`.�:.1__JLi�!_f_�•.Lti-Y%u�c�ll'l i//�ity"lTowrt`��V�_ Owner's Name ` �r:-t.F�T_._C��.l.±,7 4�L.7-' F'ttorte City r S �...�___- — Address CZ�t �'��'� Contractor's Name if'it P, ' ' '-Li License tr i /%Business Phone Contractor's Address F rgency Phone i Is Certificate of Workman's Compensation 1n urance on File With SJLHD? Yes—r l_—_ No TYPE OF WORK(CHECK): NEW WELL DEEPEN❑ RECONDITION❑ DESTRUCTION t` WELL CHLORINATION❑ WELL ABANOONMENT❑ OTHER ❑ PUMP INSTALLATION❑ . PUMP REPAIR❑ 1 +` REPLACEMENT❑ , .' DISTANCE TO NEAREST: Septic Tank —Jt*�V"' Sewer Lines _ Pit =£ Sewage Disposal ReW ' Cesspool/Ceepage Pit_ f]ther j• Property Line_ Privr;te Domestic Wetl __—_ Public Cer+estic Well _ I If INTENDED USE TYPE OF WELL r/ y�l INDUSTRIAL ❑ CAB CE TOOL Cie.of Well Excavatipn r ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casin ❑ DOMESTIC/PUBLIC ❑ DRIVEN 3 Gauge ut Casing ZO JlL, 1 © IRRIGATION GRAVEL PACK Depth of Grout Si Y ❑ CATHODIC PROTECTION ROTARY Type of Grout L' ❑ DISPOSAL ❑ OTHER _ _. Other information d ❑ GEOPHYSICAL Surface Seal installed£y: M PUMP INSTALLATION: Contractor t Type of Pump PUMP REPLACEMENT: ❑ State Work Done_ PUMP REPAIR: ❑ ^te Work Dons —. ! DESTRUCTION OF WELL: We;!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 Joaquir,County f ;j ordinar--es.state taws,and rules and regulations of the.Sa11 JoagGin Loral Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this oermil is issued. I shall nol_employc eny,person.i-q such manner as to beCgme'sytilert to workman's compensation laws of California," Contractor's hlilri' or sub-contractin Ai r at,!re certifies the following' • r ;u 9 9 9•-' g:"I fortify-ha.in the performance nM the work forwhich this permit is issued,l shall employ persons subject to,:orkman's.compensation laws of-California," IWily call for a Grout Inspection pnor t grouting and a Mina inspectlo } Signed ! .�` SLE Title: l _ Date: 1?_3 r(Craw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE l ' Application Accepted By. Date Additional Comments:—_— kL — ;< a vert Inspection Phase III Final Inspection L Inspection By Date_ �7~ �^�' — Inspection 13 i - SPe. y.. . DatA _ • - Fee I-i Due:❑ ANNUALLY ❑PER_UNIT Q PER$rTE ❑EACH ❑ JanUary 1 6 Recewed By Janeary 31 ❑July 1 8 Received By July 31 BASF. T EXPLANATION I BILL I AErriiTTANCE S: ! AMOUNT pUF C?iE!•KED I GATE DATE -,REl.IITTEO- _y--"—___ �-_„�� AMOUNT .rte_ ----- -- - 'w IEE 3 LESS I I T PRORATION -- k PLUS PENALTY �311 OTHER �'�--- -- OTHER J 3� -__I D- - Received by Dale ReCeiot No Pe-1 Nn- 151uanCe Dz:e Mi-fed Deurerea — ...— L-� 1NT�RETURNACCPIEST : ENYIRONAENTL HEALTH PERMITfSERVCEs pAPI E. AVE.. Ba•low 3TOCKTON,CA 0701 1 J 7