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FOR OFFICE USE: __�� APPLICATION 1 i_ (For��m-Transferable, Revocable,Suspendable) j't PUMP&WELL ENVIRONMENTAL HEALTH PERMIT AU U 6 (COMPLETE IN TRIPLICATE) WAT ER,Q UA LITY Application is hereby made to the San Joaquin Local Health District fora permit to constructand/or install the` 6,kl hefeln' de'JA6 .T�1is application is made in compliance with San Joaquin C 'youunty Ordinance No. 186 and the rules nd regula ns of the SanjJoaquirf Lbchkl leal1h' istrict. Exact Site Address��" 7 11� r<-11,1f1R0 - !jAL�ity/Town Y -� Owner's Name �� ' s,—t Phone J - Z �•7.5._ -- Address f� Sh Citya .2�,�= - Contractor's Name _py" � i � License# J� �J� Business Phone Contractor's Address ' G- r2 2-7 Emergency Phone T 4" Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION O- 6 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION D PUMP REPAIR❑ C> O� 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 ❑ INDUSTRIAL , ❑ 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 Surface Seal Instdlled By: PUMP INSTALLATION: Contractor Tyye of Pump H.P. PUMP REPLACEMENT: ❑ State Work Done 4;W 4.4, ( 972 PUMP REPAIR: ❑ Slate Work Done DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure �1 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. �1 Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 call for a Grout Inspection prior to grouting and a final inspection. Signed X _ rr�ryvJ= )Yi, OA m-,,,r Title: J Date: — � (Draw Plot Plan on Revers 51de) FOR DEPARTMENT USE ONLY J Q PHA Apply atlion Accepted By ��f�� f' �--f Date Additional Comments: Phas I Grout Inspection has III Final Inspection inspection By Date Inspection By YDate Fee Is Due: C3ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 -REMIT BILLING REMITTANCE $ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED _ AMOUNT FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by s Date Receipt No. - Permit No.- - I suan Dae Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 160t E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 96201 -