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rr+........... .......a. .....��.. . . . ...r...r ,......r............. .....� .....,y.. ...�..PP............. FOR OFFICE USE: I 11APPLICATION J UL 21 JL MFor Non-Transferable, Revocable, Suspendabler-011 PUMP&WELL ENVIRONMENTAL HEALTH PERMIT SAN r�i1� rr (COMPL€TE IN TRIPLICATI�EALTH L[i'^T? f.�= WATER QUALITY Application is hereby madeto t e5an Joaquln6JIN11th Districtfora permit to construct and/or install thework herein described.This application is made in compliance with San,joa County Or ' nce No.186 Od the'ruF`ps and regulations of the San'joaQu�in Local Health District. Exact Site Address /%`�� X1,1 IV (d" .W City/Town ^-OD-7- � 22 Owner's Name ��' Phone qJ 1 - zls- a Address e ��Iyn�`n,�� City S ` Contractors Name Lice seri i- _ 0.40 Business Phone47 0346V.1Z Contractor's Address Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHW Yes No TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ le- WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 131-� PUMP REPAIR El V' REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy V Sewage Disposal Fieltl Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well - INTENDED USE TYPE OF WELL L ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing )KQOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ' ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal L ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information LI 13 GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor Type of Pump H.P. PUMP REPLACEMENT: State Work Done ' PUMP REPAIR: State Work Done bae DESTRUCTION OF WELL: Well Diameter U 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. n Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 1� is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." �J lea Contractoes 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 sub act to workman's compensation laws of California." II ca or a Grout Inspe tFiii prior routing a final inspection. Signed X e. Title: Date: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASEI /� _L L, Application Accepted By A Date Additional Comments: lee Phase II Grout Inspection I Phase I a Inspection �1�'1�.� Inspection By Date Inspection By e 25 AVA Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 311 REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT FEE LESS PRORATION PLUS PENALTY Ir OTHER OTHER L l l -7 Received by Date Receipt No. Permit No i"Ilance Dalle Mailed Delivered .ew ..ur—errnou.,, mome r... cu.,,unuucurnucn,ru eeo..,rmeomree .H.a unre,rnu evc on n...Done ernerrnu ne..t --