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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. k-_-R OFFICE usE: - APPLICATION (For Non-Transferable,Revocable,Suspendable) I ENVIRONMENTAL HEALTH PERMIT PUMP St WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with r/San/Joaquin County Ordinance No.1862 and the rules and regulationsof the San Joaquin Local Health District. Exact Site Address /[_"j Irs� 6 1914 S 6 C& 1 _.........__.... City/Town Owner's Name _ L �. © � ��t'�rrl7l V Phone r Address q+¢ Q�!Lz / jI �1� � Cit int' 1� _ r� ' sine....__ S Contractor's Name _�:� � 1 ror- ,rUJitl �11I se# Business Phone 7 �' fi Contractor's Address .2022.�', C GAIT L41A 1Y Emergency Phone t Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK(CHECK): NEW WELL DEEPEN❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ REPLACEMENT❑ {4 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 ��Y$ DOMESTIC/PRIVATE ❑ DRiLLED Dia. of Well Casing �6 i ❑ DOMESTIC/PUBLIC ❑ DRIVEN ..Gauge of Casing /2 E. ❑ IRRIGATION 1:1 GRAVEL PACK Depth of Grout Sealsic-6 ❑ CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL _ ❑ OTHER Other Information 13 GEOPHYSICAL ,, Surface,Seal Installed By: PUMP INSTALLATION: r 4ontractor s ' Type of Pump H.P, k PUMP REPLACEMENT: El- Work Done, PUMP REPAIR: ❑ State Work Done - i DESTRUCTION OF WELL: Weil 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 t ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. 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:"1 certify that in the performance of the work for which this I permit is issued shall emplo persons subject to workman's compensation laws of California." 1 ail r 8r i rior grouting and a final insp I ��j C V f, i Signed X Titt7 Date: ' .S'CPT. 4 (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ON� PHASE I '�^ -� Application Accepted By� � "'^" Date � Additional Comments: j Phase If Grout Inspection Pha*RjsIII ,tea] IInnspection Inspection By?'P�;� Irk Date '� Inspection By Date i a�b Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January t&Received By January 31 ❑ July 1 A Received By July 31 REMIT ! , BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED �j AMOUNT FEE --- LESS PRORATION PLUS PENALTY OTHER - f OTHER , -? Received by Date Receipt No. Permit No- 1 ance Date . Mailed Delivered APPLICANT—RETURK ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AV£:,P.O.Box 2009 STOCI TON,.CA 9=1