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FOR OFFICE USE: APPLICATION <br /> Non-Transferable, Revocable,Suspendable) <br /> � PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> OMPLETE IN TRIPLICATE) WATER QUALITY <br /> ,_plication is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> rade in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> act Site Address <br /> . >I—,r / ��_�•—_+�_��'=-..�J:4-:a---- ----------- --- City/Town�—/ <br /> - <br /> -+ner's Name '� �~k `��s� � .: .� 1'" Phone f2✓J _ _ <br /> +ddress `. i v7 tit (� r I:i+ C( Y� City- �' _ -�i _ JJ <br /> ntractor's Name i; rq 1 . S2 t'/ 17 ,1 License If ;(9•//7 Business Phone 4/( S _S Y - <br /> -ntractor's Address Emergency Phone Z���/ <br /> s Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No r __ <br /> -"PE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONS _- <br /> -_LL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION ❑ PUMP REPAIR <br /> TEPLACEMENT❑ <br /> )1STANCE TO NEAREST: Septic Tank i;:i- 1 __ Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit _. Other <br /> Property Line/ �r+ Private Domestic Well _ _ Public Domestic Well <br /> INTENDED USE TYPE OF WELL /� <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ - `� / /j LZ <br /> r — <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 7 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> DISPOSAL Q OTHER _ _ _ Other Information r <br /> GEOPHYSICAL Surface Seal Installed By: <br /> IMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: ❑ State Work Done <br /> IMP RE1AI&:-_ C-1State Work Done <br /> �.STRUCTION OF WE-6L: Well Diameter _ Approximate Depth <br /> Describe Material a 7'd Procedure //T�_> [ �� - � �-( <br /> 13' ry� <br /> I hereby certify that I have prepared this application and that the work wi I be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued. I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued. I shall employ persons subject to workman's compensation laws of California." <br /> I 'Il call foil <br /> r e Grout Inspection prior to grouting and a final inspection. / <br /> 3ned X -s-�~�;) / f /�/ Title: Z1_- i c' I— Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By wDale 4`*_-LB-8I <br /> Additional Comments: _ <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH— ❑ January 1 &Received By January 31 ❑ July 1 B Received By July 31 <br /> -- -- -REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I -- <br /> DATE DATE ;REMITTED AMOUNT <br /> FEE �--- <br /> _ �.�. <br /> .� LESS <br /> PRORATION <br /> PLUS � — -- — ----- --------- -- <br /> PENALTY —l/ ' ---- <br /> OTHER I ^ � � �-y�, <br /> OTHER I I 1 <br /> Received by ------- Date Receipt No ---- Permit N4 ---Issuance Date MadrA—_-----ne1­­­n ------- -- - <br />