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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. FPA O.FFACE 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 C�°unty Qrdinance N 1 62 and the rules and regulations of the San J2oa�uin�Lo.,cc.a._l Health District. - Exact Site Address 7261 L lch City/Town ��1�' Owner's Name � �� 1tJt�Y�.t�- Phone Addressz�QL r-__�T-14- ' City Contractor's Name License t5wt ?l Business Phone Contractor's Address O �g �� Emergency Phone Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ' RECONDITION❑ DESTRUCTION❑/ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR REPLACEMENT❑ DISTANCE 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 ❑ ItyDUSTRIAL- ❑ CABLE TOOL Dia. of Well Excavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTiC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑ GEOPHYSICAL c Surface Seal Installed By: ... __ PUMP INSTALLATION: Contractor 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 is issued, I 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 forwhich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will If f r Grout Inspection prior to grouting and a final inspection. Signed X Title: Date: �e ✓ (Draw P Reverse Side) FO ARTMENT USE ONLY PHASE I Application Accept d By Date Additional Comments: e iI Grout I s ection (-7 hapg I ina spection Inspection By Date Inspection By 1L Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ January 1&-Received-By January 31 ❑ July 1&Received By July 31 REMIT BASE' EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE -DATE REMITTED AMOUNT FEE 5 ,0 7 C LESS PRORATION - PLUS - PENALTY OTHER OTHER o- e,..e n�e Dnreinl Al P.—if Nn IGCIIiOnA na}p Maltcd neu..—A