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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordina?ce No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address / ma b c-_-, / b e t" T✓ l�y City/Town e_:_9 Owner's Name d2 1 sz f� .n 5 I��p_ Phone Address S '�. , � � city Ad Contractor's Name n�i� Q. n X55 -F �o/'a'> License#r- 3 Business Phone 7 V J- 1 3 V 7 Contractor's AddrA;t,?ri;\_ 5 Te s (t 7Q cN 6k1 <Za j!?�Emergency Phone 5-51 M� Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL93'- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT 1:1OTHER 11PUMP INSTALLATIONB-� PUMP REPAIR❑ REPLACEMENT❑ k DISTANCE TO NEAREST: Septic Tank /deXt�4-- Sewer Lines i[StS C> Pit Privy � Sewage Disposal Field Cesspool/Seepage Pit Other d Property Lined Private Domestic Well Public Domestic Well INTENDED USE M- TYPE OF WELL ❑ INDUSTRIAL M-CABLE TOOL Dia. of Well Excavation ❑ ESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing y ESTIC/PUBLIC ❑ DRIVEN Gauge of Casingt- lig-<RIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor rJa^;%!F, Type of Pump 7w b iAV H.P. C+ PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: ❑ State Work Done 0 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. 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." Contractees hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhichthis permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for a Grout Inspection prior to grouting and a final inspection. �,+ Signed X Cm a Title: � 11 �y-'a.- \ Dater" --n q/ Vic (Draw Plot Plan on Reverse Side) l FOR EPARTMENIT USE ONLY yf PHASE 1 Ak Application Accepted By Date Additional Comments: Phase 11 Grout Inspection P,h� final Ins 7-Aion Inspection By Date Inspection By l/ f date Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ER SITE ❑ EACH ❑ January t&Received By January 31 ❑ July 1 &Received By July 31 REMIT BILLING REMITTANCE $ BASE EXPLANATION AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE LESS PRORATION PLUS PENALTY Eo V9 Ii.. C J OTHER OTHER �I (o lA 80 3'(3 d Received by I paid Receipt No. Permit No. Issuance Date Mailed Delivered