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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. FOR ONCE USE: / APPLICATION i Co N, �YElx (For Non-Transferable,Revocable,Suspendable) PUMP&WELL `---_ ENVIRONMENTAL HEALTH PERMIT t (COMPLETE IN TRIPLICATE) WATER QUALITY.. MY, - Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work,herein described.This application is made in compliance with San Joaquin County Ordin nce No.1882 eritl the rules end reguletitinsof the Ben Jamin Local ea h District._ Exact Site Address e0 Ji ye a syi%�ai�IR /- , City/Town -•IrQ r/Owner'sName Phone'• i....•• . Address Y Cit..+s . r; .•. Tplrs'/G./�. .. r> ,. ' 'ti s 1 Contractor's Name cS'f7rJ '� y'O�''� I"' Ltcertse ri 'E43�%91�13usinAss Phone••'+ Contractor's Address2620r0* Emergency Phone Is Certificate of Workman's Compensation Insurance on File Wit sJLHD9 Yes__ _ No ' TYPE OF WORK(CHECK): NEWWELLI3" `DEEPEN ❑_ -RECONDITION❑ -DESTRUCTION❑' WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER❑ PUMP INSTALLATION❑ PUMP REPAIR REPLACEMENT❑ _ - DISTANCE TO NEAREST: Septic Tank Sewer LinesPit Privy Sewage Disposal Field "' Cesspool/Seepage Pit-k-f- Other Property Line Private Domestic Well. - Public Domestic Well INTENDED USE TYPE OF WELL .. t t ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation 13 DOMESTIC/PRI VATE 13 DRILLED Dle. of Well Casing q ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ AQ IRRIGATION ❑ GtRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL- ❑ OTHER Other Information ❑ GEOPHYSICAL Surfas�al Ins[ ins^taalleedd�y: , L PUMP INSTALLATION:. a' Contractor Type of Pump H.P. ix, DUMP REPLACEMENT: +rte State Work Done_:1!%X AI `TIu ��' q&A&Aa J+- a timl1 , PUMP REPAIR: 11*13 State Work Done ... . ..,.......•.rte.,.--',....._._ DESTRUCTION OF WELL: .e—Well Diameter - +� Approximate f5epth +Describe Matelal and Procedure �• �� "i'�=tet 'I hereby certify that I have prepared this application and that the work will be Cone in accordance with San Joaquin County C ordinances,state laws, and rules and regulations of the San Joaquln Local Health District. _Homeowner or licensed agent's signature certifies 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." 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, I shall employ persons subject to workman's compensation laws of California.- �I,w�r�II call for a Grout a 1 ri d rT o gr tingAand($\fin/al Inspection. c '�—� - " f° Signed.)f�" �� ...p _ 4.L�'!� Itle: _ ' Date: O y (Draw Plot an on Reverse Side) t + ' FOR DEPARTMENT USE ONLY i y PHASE I i '`—d•S� - �t\WW + Application Accepted By Date- - � � •r !Additional Comments: phase 111 Final Inspection" Phase II Grout Inspection - Inspection By .�t..r�— Date : Inspection By yu/}-_-,.0 Date Fee Is Due: ❑ ANNUALLY ❑ PER UNITY ' ❑ PER SITE +❑ EACH• ❑ January 1'&Reoelvetl By January 31 ❑ July 1&ReOeiVlREME ayIT July 31 BILLING REMITTANCE f AMOUNT DUE CHECKED BASE EXPLANATION DATE DATE REMITTED AMOUNT s- FEE err• .y LESS PRORATION ' 'PLUS PENALTY. OTHER OTHER $. P i- - 1-ReEsiyN by • Dela. Reeelpt NQ,' + .. .. Pon Mt once �" -Mailed Delivero0 -