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&ppocangq, VIII t rroccesssa� auommea r•ropeny 1.ompiewo. oe sure I o sign I ne Appucuuun. ,, f FOR OFFICEdJSE: j P 82 APPLICATION ' (For Non -Transferable, Revocable, Suspendable) SAN O/=QUiN LO�IRONMENTAL HEALTH PERMIT PUMP & WELL HEALTH DJSTRI�T (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 Joaq}��' County Ocdinao. 1662 and the c�rules and regulations of the San o�in Local Health DistrriiR� Exact Site Address /�� 1'f�?l/i�Ld -(.{1�°� f C3�'7ff� �ei2�LG/�Qity/Town Owner's Name - _ Phone Address _. Q� j• City Contractor's Name - _..... i — License # _9�� Business Phone Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X_ No TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ —� REPLACEMENT ❑ DISTANCE TO NEAREST: INTENDED USE ❑ INDUSTRIAL X DOMESTIC/PRIVATE ❑ DOMESTIC/PUBLIC ❑ IRRIGATION ❑ CATHODIC PROTECTION ❑ DISPOSAL ❑ GEOPHYSICAL PUMP INSTALLATION: Septic Tank- c` 0— f Sewer Lines -_ Pit Privy i Sewage Disposal f=ield _ 5 ± __ Cesspool/Seepage Pit Property Line Private Domestic Well .. _ Public Domestic Well TYPE OF WELL ❑ CABLE TOOL ❑ DRILLED ❑ DRIVEN GRAVEL PACK ROTARY ❑ OTHER Contractor Dia. of Well Excavation _ // Dia. of Well Casin Gauge of Casing Depth of Grout S+ Type of Grout Other Information Surface Seal Instf .►r Other Type of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth — 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. Homeowner or licensed agent's signature certifies the following: "I certity that in the performance of the work for which this permit is issued, 1 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will 011 for a Grout Insp tion prior to grouting and a final Inspection. Signed XTitle: — — Date: 3 (Drs Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY J PHASE Q q Application Accepted By Date Additional Comments: — - __- Ph�IyGroul pection Phase III Fin � Inspection InspectiodBy Date9G Inspection By Fee Is Due: ❑ ANNUALLY' 'fl -PER-UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT CUE REMIT CHECKEp DATE DATE REMITTED AMOUNT FEE _ - L `f l LESS PRORATION - PLUS PENALTY OTHER OTHER �� V3% 1 L—:eceweo oy Uate rtece,pi NO. Permit No. APPLICANT— RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES issuance Dace manes 1601 E. HAZELTON AVE., P.O. Box 2009 To,c,:70_1:�_