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Applications Will Be Processed When Submitted Properly Com d. Be Sure To Sign TheAttiff`ion. <br />FOR OFFICE USE: APPLICATIO <br />97g <br />J <br />For Non-Transferable, Revocable,SuspendUe <br />PUMP&WELL <br />ENVIRONMENTAL HEALTH MAQUIH LOCAL <br />COMPLETE IN TRIPLICATE) WATER QUALITY . HEALTH DISTRICT <br />Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br />made in compliance with,6ayrJn CntxdIn aYnceNo.186 and the r es and regulations of the San oa uin HHea tt h D)strict. v <br />Exact Site, C j y r- <br />Lam, <br />City/Townz-1-6 <br />d rj J <br />Owner's Name! P P T ` <br />Phone Y <br />Address -7Z 6 <br />T City e <br />Contractor's Name 7` 5 License#/Z Business Pho <br />Contractor's Address Emergency Phone <br />Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br />TYPE OF WORK (CHECK): NEW WELL DEEPEN RECONDITION DESTRUCTION <br />WELL CHLORINATION WELL ABANDONMENT OTHER PUMP INSTALLATION L"f <br />PUMP REPAIR <br />REPLACEMENT f <br />DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br />Sewage Disposal Field--_.. .., ..Cesspool/Seepage At. L. ._ Other <br />Property Line Private Domestic Well Public Domestic Well <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br />e , <br />DOMESTIC/PRIVATE DRILLED ADia. of Well Casing <br />ElDOMESTIC/PUBLIC DRIVEN Gauge of Casing <br />IRRIGATIONS <br />GRAVEL PACKDepth of Grout Seal <br />CATHODIC PROTECTIONS ' ROTARY` <br />S Type of Grout <br />DISPOSAL OTHER Other Information 1 <br />GEOPHYSICAL Surface Seal Installed By: <br />PUMP INSTALLATION: Contractor 2k. _ <br />Type of Pump f P.t <br />PUMP REPLACEMENT: State Work Done <br />PUMP REPAIR: State Work Done <br />DESTRUCTION OF WELL: Well Diameter r <br />1 <br />Approximate Depth <br />IL <br />Describe Material and Procedure <br />I hereby certify that I have prepared this application and thatthe work will be done in accordance with San Joaquin County <br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />Homeowner or licensed agent's signature certifies the following:''I certify that in the performance of the work for which this permit <br />is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br />con'racfo ' ring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br />Perm sued, I shall e Ioy persons subject 16-workman's cbmpen i 1'awsof California." <br />E i rout In ec ion'prior to grouting and a final inspec n. <br />J 7 <br />Signed XTitle 'Date.l <br />Draw Plot Plan on Reverse Side) <br />F R DEP RTMENT SE ONLY <br />PHASE I <br />q <br />Application Accepted By— Date G / <br />Additional Comments: <br />Phase II Grout Inspection Phase III Final Inspection <br />Inspection By Date Inspection By Date <br />h <br />I <br />Fee IS Due. ANNUALLY PER UNIT 1 r PER SITE EACH January 1 &Received By January 31 July 1 &Received By July 31 <br />BILLING REMITTANCE <br />REMIT <br />BASE- EXPLANATION <br />DATE DATE REMITTED <br />AMOUNT DUE CHECKED <br />Ap AMOUNT <br />FEE s- <br />LESS <br />PRORATION <br />PLUS 1 <br />PENALTY 2 , <br />OTHER <br />1 <br />OTHER <br />y <br />7.: -—k\ 97 <br />1ReceivedbyDateReceiptNo. Permit No. - Issuance ate Mailed Delivered ^' ,•. + <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-ECHAZELTON AVE.'`P;OrBoe"2009-t S, CKTON i