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Applications Will Be ProcessedWhen SubmittedPropertyeomplecee.meoure, rVary,r .rra•+rr••--••-••• FOR OFFICE USE: APPLICATION - 1xMifor Non-Transferable, Revocable,Suspendable)v,.,� PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (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 :Wade in compliance with Sanoaquin County Ordinance No. 1862 and the rules and regulations of the San oaq in Local Health District. Exact Site Address ��///Z7V Miarc 6rouc. XrJ Citylrown A091' Owner's Name TIetr-5 / T/AV,'d Phone -5-2-7` 1 2 Address /e /L_Rl/.er- TLCJ City Al ES70 Contractor's Name CLARK IU17-LF FA- 01A Ca. .-_7iQ. License#_&60 2 Business Phone Contractor's Address 2424 F GIU.4 If- WA 4 Emergency Phone I,Vd Ale' Is Certificate of Workman's CompensationInsu nce 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[] /VQ-J Ar /S r. 4,1 j AT TK/zt DISTANCE TO NEAREST: Septic Tank -4 G r �ASewer Lines + 6 / Pit Fri Sewage Disposal Field 7NG• GV Cesspool/Seepage Pit A)It• Other Property Line y's . Private Domestic Well 300 ' Public Domestic Well INTENDED USE TYPE OF WELL /O r/� N ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation -yr — DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing G 6 - O ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �1 S7�E� / ❑ IRRIGATION t13 GRAVEL PACK Depth of Grout Seal �d ❑ CATHODIC PROTECTIONROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor 15m WELG EotfIe c0 _rA-V_ Type of Pump 54 B• 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 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." I w_,�il..I all for a Grout Inspectio prior to grouting and a final inspection. / /y 7 /'� �tiT.e,/'LL Date: .(1 Signed X , m .Z iii Title: (Draw Plot Plan on Reverse Side) FOR DE ARTMENT USE ONLY PHASEIy 77 Application Accepted By •^^ Date %�UU Additional Comments: Phase II Grout Inspection Phase�Finaaction Inspection By • �• Date 9- � Inspection ByDate Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January/8 Received By January 31 ❑ July 1 K Received EBMyl July 31 BASE EXPLANATION BILLING REMITTANCE t AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT v FEE LESS PRORATION PLUS PENALTY OTHER OTHER Delivered Received,by Dale Receipt No. Permit No. I� nce Date Mailetl APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1fi01 E.Hp2ELTON AVE.,P.O.Boa STOCK N,CA�i� '