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Appiintlons Will Be Processed When Submitted:Propeny- . FOR OFFICE USE: APPLICATION - (For Non-Transferable,Revocable,Suspendable) PUMP&WELL nENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) T�(So N o-�� 1 t`�'4`fQUALITY Of-7-0'10—0 ft Application is hereby made to the San Joaquin Local Health Distric or 7mittoconstructandiorinstalltheworkhereindescribed.Thisapplicationis made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. (,�� (/ sus p7 y� priq.,_.Q. City!Town ' Exact Site Address �- /11L- A / �CL4,v_M_LAe r .r-_�— vC-k— Phone� Owner's Name Address City��s� (3—,�- rte- Contractors Name UN1 tf� r�j� License Business Phone S Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No _ �1 TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR�� REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank _RC1 d�L- Sewer Lines __�� Pit Privy ___OL� �'^ �— Sewage Disposal Field_ _ Cesspool;Seepage Pit �(,��r — Other Property Line Private Domestic Well Public Domestic Weil INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation — ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing _ - — ❑ DOMESTIC/PUBLIC O DRIVEN Gauge of Casing — - - 93-TR'RIGATION ❑ GRAVEL PACK Depth of Grout Seal .... - 1 r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER _ Other Information _._ 49 ❑ GEOPHYSICAL Surface Seal Installed By. PUMP INSTALLATION: Contractor-0 NI/✓ P/t f�L�_--� � p - -I Type of Pumper b,do H. -- --- PUMP REPLACEMENT: 11 State Work Donee PUMP REPAIR: R'Mate Work Done LCA - 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i Borne owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit T4 ! 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." 1 will call for a Grout Inspection prior to grouting and a final inspection. �. Signed X _41A , Title: Dale: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I Siad. Application Accepted By `�"�`^"' Date Additional Comments: Phase 11 Grout Inspection Phase III Final Inspection Inspection By Date ___ Inspection By. � Date i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACN ❑ January 1 &Received By January 31 ❑ Jury' A Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE ' $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION _ -- rLus PFNALTY OTHEn OTHER ered__ -- Received by Date Qecetpt No Permit No ( Date Mailed DelC APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 5601 E-HAZE AZELTON AVE.,P.O.Box 2009 $TDCKTOTON,CA 93]05