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Applications Will Re Processed When Submitted Property Completed. Be Sure To SIg0 The Application. Fop OFFICE usE: t Xz APPLICATION �a�i �� (For Non-Transferable,Rerocable, Suspendable). PUMP 8 LL ENVIRONMENTAL HEALTH PERMIT v'' rl�Ar/ )MPLETE IN TRIDLICATEj WATER QUALITY *VSE � pplication is hereby made to the San Joaquin local Health District for a permit to construct and/orinstali ttRework cram described.This application is made in compliance with San Joaquin County Ordin' N 1862 and the rules and ulatioro of the San Joacl6 n 4oyel jleal�riot. Exact Site Address /1�P'S f _- yr4Z =g02-42Crty/Town C��'1�`--Y��'.• Owner's Name �in!t '`A�4lM r �— — Phone !1 ��t"'SQRL ^k!� City Address Contractor's Name � ��/ �IG .� __� ---- License M BtB!!�c Ph[x�a Contractor's Address ✓�'s�ts��rT�mergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLyD9 YesNo - V+ TYPE OF WORK(CHECK): NEW WELL DEEPEN ElRECONDITIONDESTRUCTION❑ WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PLOAP INSTALLATION 1!9 PUMP REPAIR Ir REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Feld CesspooUSeePage 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 DOMESTICIPUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL ' Surface Sea_ In%led By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: q❑ State Work Done `UMP REPAIR: /-. State Work Done P14 -- _jESTRUCTION OF WELL' Well Diameter Approximate Depth Describe Material and Procedure 1 hereby certify that I have prepared this application and that the work will be dons in accordance with San Joaquin County (j1 ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. (n Home owner or licensed agents 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 Califomia." Contractor's Hiring or subcontracting signature certifies the following:"i certify that to the performance of the work for which this permit is issued. I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Ins"c M Ung a final inspection. 4�_ Date: Signed �" (Draw Pb Ian on Reverse Side) FOR DEPARTMENT USE ONLY PHASE IDate Application Accepted By Additional Comments. Pira 111 Final Inspection (D� /�IPPhase U Grout Inspection . _ Date OO inspection By '"� Date _ Inspection BY� Fee is Due: O ANNUALLYO vet tau* ❑ PER smE ❑EACH ❑ aw usn,I a Ascakee g'jv"w 31 a u"h t a Itece�.ed By�y 31 FlEMIT SASE EXPLANATION NTNG REMI TA TE ANCE �O AMOUNT DUE ECAMOED FEE 4 � s45d y LESS PRORATION PLUS PENALTY OTHER v� OTHER eas l 3 l05 ' i� 8i81 ma�Mass �,N,,, Received er Date Remipn No- Pwmi No. APPLICANT—RFNRN ALL COPES TO: EnnyatON11ENTK IwAllll9ETYRAtaRMCEa laN G RiAaTll'dN AYE.1A.as aM 5iOCR70R G laMt'