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Applications Will Be Rrocessed When Submitted Properly Completed. Be Sure To Sign The Application. 6FOR OFFICE USE: APPLICATION (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby ma&to the San Joaquin Local Health Districtfora permit to construct and/or install thework,hereindescribed.This application is 1 ,.. made in compliance with San Joaquin County,i Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address end of K— ;� *� :1 'i'Yl t i tv r� f5y I'f."o' `r4 w U. City/Town =Y-ar U �J(� Owner's Name ��1 . DQ V i Phone (J}' '-_57 , Address ��. � ��i'"c� City {�j��Q'Y-lr'j �� '-��tnQ t _ I Contractor's Name k k'\ S J 7 i t i License# Business Phone Contractor's Address !rgency Phone _ t !� Is Certificate of Workman's Compensation Insurance on File With SJLHD? .Yes h` No TYPE OF WORK (CHECK): NEW WELL 0- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ �. REPLACEMENT❑ h 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 - o r El-DOMESTIC/PRIVATE Ga'DRiLLED Dia. of Well Casing b ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _� ❑ IRRIGATION l� GRAVEL PACK Depth of Grout Seal �A S0 , ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r)i ❑ DISPOSAL ❑ OTHER Other Information '1/ d Ouunfr ❑ GEOPHYSICAL Surface Seal Installed By: p/}I'1Inn PUMP INSTALLATION: Contractor Type of Pump H.P. 4 PUMP REPLACEMENT: El:IState Work Done y PUMP REPAIR: ❑.State Work Done F DESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure p� 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 for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." II will call for a GroutInspectionprior to grouting and a final inspection. Signed X�2_r3 l!1 .��i_, �L. JL/_ Title; n p f�'f�-I.I Date: (Draw Piot Plan on Reverse Side) �l PHASE I FOR PARTM T USE ONLY t Application Accepted By i �`"'" Q-7 Date Additional Comments: Phas`e�l.1 Grout j Inspection3` k k Phase III Final. Inspection Inspection By Date 1 I Inspection By Date Fee IS Due: ❑ ANNUALLY ❑ 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 rf PRORATION PLUS } PENALTY OTHER i.F i OTHER . Received by Date Receipt No Permit No. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 WCKTON,CA 95201 - 'm'