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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTneAppticauon. APPLICATION FOR.OFFICE USE: (For,Non-Transferable, Revocable, Suspendable) PUMP&WELL 'ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY 4 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 9 made in compliance with an Joaquin vu Ordinance No. 1862 and the r les and regulations of the San J/� Local District. r Exact Site Address + J A City/Town _/ � Owner's Name r P-V+ et n.. Phone _ I� W1 Ito W City / Address � ^ Contractor's Name rre i,4 &zP,ff b no r License# f3eJ,/23Business Phone i Contractor's Address.t.22e2o S"s.J ,'� Qpl rgency Phone Is Certificate of Workman's CompensationIns ance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL EPEN ❑ RECONDITION q w. DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION'fil,_ PUMP REPAIR❑ : REPLACEMENT❑ � 4 fp z 1I� �� e DISTANCE TO NEAREST: Septic Tan , 0AJ Sewer Lines A-'F7lL1� Pit Privy /" r Sewage Disposal Fie/l�d_ s9 tL1g Cesspool/Seepage Pit 1� R1� Other N� Property Lin/09OP—Private Domestic Well W04yePublic DomestictWell; IVO 4-�G p' INTENDED USE TYPE OF WELL i ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation 'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �`lir ilow ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout e A-,-' 7 ❑ DISPOSAL ❑ OTHER Other Information 13GEOPHYSICAL SF 'face Seal Installed f3 t aEf lQ elf Jf C PUMP INSTALLATION: Contractor 4J r Type of Pump �"� H.P. f' PUMP REPLACEMENT: ❑ state Work Done Y PUMP REPAIR: ❑ State Work Done rt DESTRUCTION OF WELL: Well Diameter Approximate Depth L Describe Material and Procedure , I hereby certify ihat I have prepared this application and that the work-will.be done in accordance with San Joaquin County J }} ordinances, state laws, and rules and regulations of the Sari 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 is issued, I shall not employ any person in such manner as to become subject to workman's--compensation laws of California." i Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued,`I shah employ persons subject to workman's compensation laws of California." 3 I wit call for a out Ins tion prior to grouting and a final Inspection. Signed X / a _ Title: — �Y'r..!"hy.�si �. Date: s (Draw Plot Plan on Reverse Side) p = FOR DEPARTMENT USE ONLY ( PHASE I � pate 2 � Application Accepted By F Additional Comments: Phase II Grout Inspection Phas !1 Final Inspection ' > Date Inspection By Date inspection By Fee l5 DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By"January 31 July 1 &Received By July 31 REMIT BILLING REMITTANCE $ -�----- AMOUNT DUE CHECKED - BASE EXPLANATION DATE DATE REMITTED. - AMOUNT FEE ��.� .. - - .ru ...- ,r.. ri—r..-. .— ...., mm —y�^•-•-- �,� -. /�-,... - t f� LESS PRORATION r PLUS ' i I PENALTY - F ' OTHER OTHER ttp -7 D _ Issuance Dat Mailed Delivered - Received by-- - ate =�Receipt-No:� Permit No. t APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE P.O.Box 2009 STOC r`D''�'