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r r applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ^FOR fUSE: APPLICATION (For Non-Transferable,Revocable,Suspendable) ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instail the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address Z1191Z 09 -1111 P City/Town Owner's Name N 11 ,./� AddressPhone rvda All City- G ri .� Contractor's Name License fi 0" O Contractor's Address Business Phone one is Certificate of Workman's Compensation Insurance on Fi With SJLHD7 e�Yesy Ph1 No l TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION 11 WELL ABANDONMENT 11 OTHER 13ATION -� PUMP REPAIR❑PUMP INSTALL % � REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit PropertyOther Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation ff?7U`5MESTIC/PRIVATE ❑ DRILLED Dia"of Well Casing pe ❑ DOMESTIC/PUBLIC ❑ DRIVEN IRRIGATION Gauge of Casing , ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY ❑ DISPOSAL Type of Grout ❑ OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By; PUMP INSTALLATION: Contractor il I,111 01&A e-des!,Illllllllll 110, Type of Pump 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. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit i is issued, l 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 will call for a Grou speclion prior tp grouting and a final inspect Signed X Title: Date- (Draw Plat Plan on Reverse Side) PHASE FOR DEPARTMENT USE ONLY Application Accepted By Additions!Comments: + Date Phase 11 Grout Inspection a III Final Inc Inspection By \( bate pection . Inspection B Date Fee 15 Due:11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I&Received By JanuerY 91 ❑ July t a Received gy Juiy 91 � BASE EXPLANATION BILLING REMITTANCE $ REMIT DATE DATE REMITTED AMOUNT DUE CHECKED FEE AMOUNT y5. 00 LESS 7 PRORATION PLUS PENALTY OTHER OTHER Received by pale Recei t No. ��—ff p Permit No. Issuance Date Moiled APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMTTISERVICES tlelwered - _ tagl E.HAZEiTON AVE.,P.O.Box 2068 STOCKTOM,CA 83Z