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Applicatlons Will Be Processed When Submitted Properly Completed. Be Sure To Sign 7he.gpplicatio- �F I E USE:'" I n. APPLICATION 1 (For Non-Transferable, Revocable, Suspendable) k ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District fora perms t to construct and/or install the work herein described.This application is 1 made in compliance with San Joaq�uy� Coun Ord' ce No. 186 a d the rule no regulations of the San Joaclap o al Health District, Exact Site Address /V6a. ' e J --wi-err` City/Town ��F Owner's Name -V ist.1200 Phone a • Address City— Contractor's ity i ContractoisName o.. LicensefF /f'd?J}d B sinessPhone- ' 1-7 ? 4f 7 Contractor's Address w .Emergency Phone I Is Certificate of Workman's Compensation Insurance on F'1 ith SJLH07 Yes�X� No TYPE OF WORK (CHECK): NEW WELL DEEPE ❑ RECONDITION❑ DESTRUCTION❑ G WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR G REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Sewage Disposal Field _"..Cesspool/Seepage Pit Other Property Line Private Dome c Well Public Domestic Well INTENDED USE '• TYPE OF WELL t ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation W DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN _ Gauge of Casing ❑ IRRIGATION ' _ ❑ GRAVEL PACK Depth of Groµt Seal t 11 CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL OTHER Other Information ❑ GEOPHYSICAL Surface Seal Installed By: PUMP INSTALLATION: Contractor----jam- / TYPe of Puma— Snr�E.e,rc ._d H.P.. e_<< PUMP REPLACEMENT: .P,�y,,State Work Done ` PUMP REPAIR: ILI State Work Done aMe&eoet 1AP&I.V �AKA6b P DESTRUCTION OF WELL: Well Diameter '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 ork 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 for which this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." I wl1 call for a Grout Inspectl IT ri to r In and a al inspection. / Signed X - • / V , ills: Pim Jr, r Date: (Draw Plot an on Reverse Side) - IF F RD PARTME Irf USE ONLY - - PHASE I 1 Application Accepted By • X Additional Comments: f 30 e Date J 4 Phase 11 Groutnsp/ction he I al Inspection cy Inspection By ` Date Inspection By Date 45-0 F!!In Due: ❑ ANNUALLY [3PER UN 4❑ PER SITE ElEACH ❑ January 1 8 Received By January 31- t ❑ July 1 8 Received BY July 31 BILLING 'REMITTANCE K BASE EXPLANATION S )AMOUNT DATE DATE REMITTED FEELESSPRORATIONPLUS +. 'PENALTY •••'t: I _. _. ,OTHEROTHER -5�3 s IR BCS Received by -w.�+•pata:' _.Receipt No. ...�"- Permit No. Inuarce Deb MNred Da11JerM _ .m........ ....,.....,. .....___ _-....__