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Applications Will Be Processed When Submitted Properly o FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELLS I ENVIRONMENTAL HEALTH PERMIT WATER QUALITY (COMPLETE IN TRIPLICATE) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance NO•1862 and the rules and regulations of the San Joaquin Jl,o_c? alt District. f -�LIIA L� IwJ /�� J� Exact Site Address City/Town�I h - Owner's Name Q �v 1iry Phoney � - 1 07 5,4rf' City ? AddressI'll �� G2—'�5 Contractor's Name �� f� ��, '�. icense# Business Phone Contractor's Address 2 Emergency PhoneJ Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Y No TYPE OF WORK (CHECK): NEW WELL NMEEPEN❑❑ OTHER N❑DITIO N❑P INSTALLATIONN ❑❑ PUMP REPAIR ❑ ` j :.. WELL CHLORINATION 11 WELL ABANDO REPLACEMENT❑ / � [,ar U Sewer Lines Pit Privy � f DISTANCE TO NEAREST: Septic Tank Other Sewage Disposal Field Cesspool/Seepage Pit Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 11 INDUSTRIAL 1:1 CABLE TOOL Dia. of Well Excavation IN DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION 10 ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. � i PUMP REPLACE IENT: ❑ State Work Done EE PUMP REpd ❑ State Work Done F Well Diameter Approximate Depth t: DESTRUCTION OF WELL: F Describe Material and Procedure r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f 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 for which this permit I 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 Is l ped, I shall employ persons subject to workman's compensation laws of California." will r a Grout inspection prior to groulin d a final inspection. f • Sig ed X Title: Date: (Dr t Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE I ' Date6 Application Accepted By Additional Comments: base orout Inspection� � h e III Final Inspection f � Inspection By Date Inspection By at Fee IS DUB: 13 ANNUALLY ❑ PER UN1T ElPER SITE ❑ EACH ElJanuary 1 &Received By January 31 ❑ July 1 &Receiv REMITd By uly 31 { BASE EXPLANATION BILLING - REMITTANCE $ AMOUNT DUE CHECKED 1 DATE DATE REMITTED AMOUNT r FES 7 LESS I PRORATION PLUS PENALTY OTHER OTHER Date ,Receipt No. Permit NO. Issuance Hate Mailed Delivered Received by RN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTUN AVE.,P.O.Bax 2009 STOC%TON,CA 952 APPLICANT—RETU