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FOR OFFICE USE: APPLICATION (For Non-Transferable,Revocable,Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT OMPLETE IN TRIPLICATE) WATER QUALITY Iippl ication is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work.herein described.This application is nade in compliance withSan Joaquin County Ordina/n�Ce�N(o.1862 and the rules and regulations of the San Joaquin Local Health District / act Site Address // F/ /�Q N, t('W - City/Town 1,6dr-A- A 52( t) 1 � C Owner's Name Phone tddress it/ 70 AJ City mtractor s Name E,jf,�an� - License fl Business Phone `mtractors Address Emergency Phone s Certificate of Workman's Compensation Insurance on File With SJLHD4 Yes No L wPE OF WORK (CHECK): NEW W RECONDITION❑ DESTRUCTION _ =LL CHLORINATION ❑ WE LL ABC ANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 4EPLACEMENT❑ )ISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool/Seepage Pit Other Property Line - Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL INDUSTRIA ❑ CABLE TOOL Dia.of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing LIC ❑ DRIVEN Gauge of Casing 3 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal CATHODIC PROTECTION ❑ ROTARY Type of Grout — DISPOSAL ❑ OTHER Other Information 3 GEOPHYSICAL Surface Seal Installed By: IMP INSTALLATION: Contractor tee Type of Pump H.P. (LIMP REPLACEMENT: ❑ State Work Done IIIMP EP UR: ❑ State Work Done (� :STRUCTION OF WELL-- Well Diameter Approximate Depth OI .,{� ,,.(�' yp .11 Describe Matter[t',al and Procedure �� / ) icy`\ cqSi "II `} S)¢ 4Js.d- 4�—�0 / --(Jr�--C „r--- aLc) Sri F [s-QCs. 1 hereb certify that I have prepared this application and that the work will be done in accordance with San Joaquin County _ r ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certMw the following:"1 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." Contractofs hiring or subcontracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will call for Grout spection prior t routing and a final inspectio `,— y fned X Title: Zv" Date: 7" (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY PHASE [ Application Accepted ev Date Additional Comments: Phase It Grout nspection ase Final Inspection XIS Inspection I "bate-- Inspection By 2 Date Fee Is Due: ❑ ANNUALLY ❑'PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1&Received By July 31 BILLING - REMITTANCE f REMIT v. BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED 00 AMOUNT FEE LESS y PRORATION PLUS PENALTY OTHER r OTHER X07 2/ ,.� Received by Dale Receipt No. Permit No. Issulince Dafte Mailed Delivered — APPLICANT—RETURN ALL COPIES TO- ENVIRONMEWAI HFAI TM CFRWT/CFRVrfFR ♦u�v Mwnraw wv n� a__n„M n�M..�.... ..........