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Applications Will Be Processed When Submitted ProperlyCompleted. BeSureToSignTheAppiicatio . FOR OFFICE USE:go APPLICATION �$ i (For Non-Transferable, Revocable,Suspendable) PUMP P4 ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin CoOrdinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address & unt [Z h City/Town AC4, ty, A r, Owner's Na e G Phone -5 3 4/ — Addresstai dee)d City C Contractor's NameRc L i� Q�� hr r`N' License#Xi�lf_/13 Business Phone S & 9- l G 719 Contractor's Address .`t , "', d M ergency Phone p ' Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Na !" TYPE OF WORK (CHECK): NEW WELIMC DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ -0 .--- DISTANCE __DISTANCE TO NEAREST: Septic Tank Sewer Lines J&D Pit Privy Sewage Disposal Field e_ Cesspool/Seepage Pit O Other Property Line/&I�_(-Private Domestic Well Public Domestic Well '� - INTENDED USE TYPE OF WELL ❑ INDUSTRIALGABLE TOOL Dia. of Well Excavation J .pOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing �i ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �Z ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ _Ra i rI A,' 'sti- ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor iG i M,g/ Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done y 1 PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter y-�l Approximate Dept 47d � 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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:"l 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 ill call for a Grout Ins ection prior to gr uting and a final inspection. c-^ Signed X �-C.�/f /� - Title: Date:`� ~ J (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY j/ PHASE I r Application Accepted By Date Additional Comment d P a e II Grout InspecU n se III Final Inspection t Inspection By Date Inspection By Date 1/ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received By July 31 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE �- LESS PRORATION PLUS PENALTY OTHER OTHER 1 �t) Received by date Receipt No. Permit No. Issuance Date Maiied Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201