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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. FOR OFFICE USE: 0 APPLICATION E G'. (For Non-Transferable, Revocable, Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP 'WELL (COMPLETE IN TRIPLICATE) � �- WATER QUALITY ba.-, Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described This application is €k made in compliance with San Joaqu County 0,4nance No. j 62 and the rules god regulations of the San Joaquin ocal Health District. I Exact Site Address I �_ City/Town �, ,� Owner's Name ITI. r Phone Address City '. Contractor's Name d Licens Business Phone, ; Contractor's Address o2 S� 9' � „I ��,._P Emergency Phone Is Certificate of Workman's Compensation Insurance on File'With SJLHD? Yes No :! TYPE OF WORK (CHECK):. NEW WELL 9"—DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 09 PUMP REPAIR 11REPLACEMENT© � ,: DISTANCE TO NEAREST: Septic Tank' "7� Sewer Lines — Pit Privy �Q &` Sewage Disposal FiW Cesspool/Seepage Pit �;l- Other i. I Property Line Private Domestic Well Public Domestic.Well k l INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation E�' ICAESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ 6.R7b/EN{'� '�, Gauge of Casing F El IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I ❑ CATHODIC PROTECTION NARY Type of Grout 4 <f ❑ DISPOSAL ❑ OTHER Other Information fI l ❑ GEOPHYSICAL Surface Seal Inst ed By: �..JJ� PUMP INSTALLATION: Contractor ?LJ� Type of Pump H.P. i d PUMP REPLACEMENT: ❑ State Work Done'- l� PUMP REPAIR:' ❑ State Work Done - 1 DESTRUCTION.OF WELL: Well Diameter Approximate Depth Describe Material and Procedure f 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 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." Contractor's hiring or sub-contracting signature certifies thefollowing:"I 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 will calf or a Grout Inspection prior to grouting and a final inspection.- Signed nspection.Signed X �� =-Title: .. Date: (Draw Plot Plan on Reverse Side) R DEPARTMENT USE ONLY PHASE s Application Accepted By ' Dat,-_;/- 2-// Additional Comments: a Phase 11 Grout Inspection Phase III Final Inspection Inspection By DateInspection; C Inspection By Date w Fee Is Due:-0 ANNUALLY 13-PER UNIT 0 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy t &Received By July 31 REMIT It .BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED t DATE DATE REMITTED AMOUNT FEE i LESS y PRORATION - PLUS PENALTY OTHER - A OTHER 41 -79 Received by - - Date - r Receipt No. ,Permit 12 - a Issuance Date .Mailed - Deliver � =APPLICANT—RETURN ALL COPIES TO 'ENVIRONMENTAL HEALTH PERMIT/SERVICES I` - 1601 E.HAZECTON AVE.,P.O.POaoxt2tll•19 '[TOC ON,CA 95241 F ' ..