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Applications Will Be Processed When Submitted Properly Completed.Be SureTo51gn rne►apP116a1LTVn.� FOR oFFIE use. APPLICATION (For Non-Transferable,Revocable,Suspendable) PUMP&WELL g-_ ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY„ y • t� ar't 2`�tk.CY tt rye..,. Application is hereby made to the San Joaquin Local Health Districtfor a permitto construct and/or install the work herein described.This application is i made in compiiance�prith Sin oa uirL,County.Ordinance t 62.and the.rules and regulations of the S n Joaquin Local Hea1t{ i ict. k G' �.:, c �.. w Exact Site Address s k. ' /),'IIZ4 c�.C� /� — 3' M, 4. usr. .. r.. *"_ .' ► Phorie i Owner's Name.' �,Q1sy `• - •,:; �.: :..L:./d,,( G?�l�-. •r. City ' Address � L� _ , CfC' License# j" �2r'Business Phone Contractor's NamA, -". - Contractor's Addre %3 "T� `Emergency Phone s No Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - _ TYPE OF WORK (CHECK): NEW WELL❑ W DEEPEN ❑ RECONDITION 13DESTRUCTION NDONMENT ❑� OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ WELL CHLORINATION 1:1 WELL ABA REPLACEMENT 13 --- DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other } Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑,(INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing t /❑_ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION " 1:1 GRAVEL PACK Depth of Grout Seal O CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL C1 OTHER Other Information ❑ GEOPHYSICAL Surf eat eal lnstalied By' PUMP INSTALLATION: Contractor ;;. .Type of Pump r x H.P. PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: i ❑ State Work Done M DESTRUCTION OF WELL:---�— 1Well 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 h i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District._ E "I certify that in the performance of the work for which this permit Home owner or licensed agent's signature certifies the following:become subject to workman's compensation laws of California." is issued, I shall not employ any person in such manner as to Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this l per s issued, I shall employ persons bject t workman's compensation Laws of California." '1 III 'all for a Gr t inspection p Ior t �grouii g and a linal insp lona ' Title: Signed X Dale: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY T _ PHASE I r DateC9 Q Application Accepted y ' Additional Comment Phase 11 Grout Inspection P e II Final Inspection Date Inspection By Date �' `gZ=" z Inspection By � Fee Is Due: ❑ ANNUALLY `W�❑ PER 6WT ❑ PER SITE" ❑ EACH January 1 &Received By January 31 ❑ July 1 &Receiv REMITBy uly 31 BASE` EXPLANATION BILLING- _-_ # REMITTANCE $ -AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE .. LESS I PRORATION - - -' .t :�. .}- PLUS PENALTY OTHER OTHER _ r - S , ` rDate - � ��- �•Receipt No. ll Permit No. � - issuance-bale t... Mailed - Delivered, Received by ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 76x1 E.HAZELT4N AVE.,P.O.Bax 20 09 57OCKTON,C0.95201