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wl Applications Will Be Processed When Submitted Properly Completed Be SureTo 51gn tneApplication. FOR OFFICE lyse: APPLICATION j (Fot,Non-Transferable, Rev c e, u n $bl v. PUMP&WELL ENVIRONM 4T PERMIT QUALITY c� (COMPLETE IN TRIPLICATE) Application is hereby made to the San Joaquin Local Health District for it str c n /or install the work herein described.This application is made in compliance with San Joaqui County Ordinance No. 1862 and the rules and reg�u.�la tjogs(ef7�San o quin c Health District. I �V L n Exact Site Address Z m0 j g H DSS1� �3 f Owner's Name —T ��- Phone Address City Contractor's Name License #�� 7 Business Phone 7`sd G '91 r Contractor's Address _ Emergency Phone l ✓ Is Certificate of Workman's Compensation Insurance on File With SRECO Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR O REPLACEMENT❑ Vi DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privyr Sewage Disposal Field Cesspool/Seepage Pit Other � Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL r .. --_ l 1:1INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation i 11 DOMESTIC/PRIVATE �❑ DRILLED Dia. of Well'Casing DOMESTIC/PUBLIC ❑ DRIVEN - Gauge of Casing C © GRAVEL PACK-...: Depth of Grout Seal ❑ IRRIGATION 1:1CATHODIC PROTECTION ❑ ROTARY Type of Grout C _ G F ❑ DISPOSAL OTHER- Other Information i ❑ GEOPHYSICAL S rface Seal Installed By: PUMP INSTALLATION: +Contractor Type of Pump H.P.. PUMP REPLACEMENT: ❑ State Work Done'- PUMP REPAIR: State Work Done *- ` } DESTRUCTION OF WELL: Well Diameterp 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 regulationsYof.the San Joaquin,Local Health District. r Home owner 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 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 all 1101 a Grout Inspectio prior to grouts and a final inspection. Signed X __Pke: �n Date: - u ^'^ """"•-"'""(Draw Plot Plan on Rever Side) - FOR EPARTMENT USE ONLY e PHASE..1. + Date t' Application Accepted By Additional Comments: k Phas l Grout Inspection Pha a III Final Insp ciion Inspection By Date Inspection By_jb, I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv d By REMITuly 31 BASE EXPLANATION BILLING REMITTANCE $ .AMOUNT DUE CHECKED ( DATE DATE (REMITTED AMOUNT F1=E LESS PRORATION PLUS PENALTY i OTHERw DTHFR Received by -Date , 'Receipt No, Permit No. Issuance fDaleMailedAPPLICANT--RETURN ALL COPIES TQENYIRONMENTALHEALTH PERMITYSERVICES 1601 E.HAZELTO.