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Appncaaons will ne Il-rocesseo nrnen mamrneo Irropeny i,ompierea.ne*ure e o i rgn I ne Application. FOR OFFICE USE: APPLICATION /—o-7-- 18 • (Far Non-Tranafereble,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 Count ,Ordinance No. 1862:and the rules.and regulations of the San Joaquin Local Health District. Exact Site Address 32 L�M JL��_ City/Town Owner's Name (ysti�Yne' .`Cj Z Address l ai• �� — '. i�7.(� 7 1 ��r' rF •.I Vlty, Contractor's Name C= 's, `t - �. License#- a:!f7 Business Phone Contractor's Address 1`'. V'Emergency Phone r' r ' Is Certificate of Workman's&mpensatiorlInsurance on File With SJLHD? Yes _ No TYPE OF WORK (CHECK), NEW WELL❑- DEEPEN ❑ RECONDITION❑ 4 DESTRUCTIO,NN11 'WELL CHLORINATION❑ WELL ABANDONMENT 13 OTHER 11 PUMP INSTALLATION Ell PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST: Septic Tank _ Sewer Lines _tPit Privy Sewage Disposal Field___..___ Cesspool/Seepage Pit Other Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL ❑ IfypFJSTRIAL ❑ CABLE TOOL Dia. of Well Excavation .- I/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 Installed By: PUMP INSTALLATION: Contracta>< OL Type of Pump H.P, ---- - PUMP REPLACEMENT: ❑ State Work Done PUMP REPAIR: E3,-State Work Done -- .— DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure S I0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 7 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Cf 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•eontracting 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." ra Grout In cellon prior to grouting and a final inspection. Sig 0 , Title: _ -- - - - --- ------- Dale: (Draw Plot Plan on Reverse Side) FOR DEPARTMENT USE ONLY r PHASE t Application Accepted By ( -- - / /--� --- ' Dated =/ Additional Comments: - Phase 11 Grout Inspection h ste incl Inspection Inspection By __ Date -_ .. -• ! _— Inspection By _ Date Fee Is Due: ❑ ANNUALLY ❑-PER UNII ❑ PER SITE 1❑ EACN t' •❑ Jinuary 1 8 Received By JanuAry 31 ❑ July 1 d,Received By July 31 REMIT BILLING e: REMITTANCE ` S BASE. EXPi ANATION DATE DATE REMIITLD AMOUNT DUE AMOUNT O FEE.. � ..._. _ 7, LESS r t PRORA1 ION .PLUS PENALTY 4 r t r OTHER .. - ...� „µ •{ .q... - OTHER .- .. ._ •r ;- _ i. r --.t _ -Received by Datc - Receipt NO - Permit No - lssArke Date Mailed' Delivered APPLICANT-RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON•CA 95201 _