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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> FOR OFFICE°USEr_ APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> I PUMP&WELL � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE WA ER QUALITY <br /> Application is hereby made to theSan Joaquin Local HealthDistri or rtrmito�co structand/or install the work herein described.This application is <br /> made in compliance with San Joaquin�C_ounnty Ordinance o. 1862 an the rules and re ulations of the San Joa}uin Local Health District. <br /> Exact Site Address CQ or fQ.I�E�tJrx+ cSf/' ure k/*5y0 � Addy GCity/Town STpc�TO7 <br /> f Owner's Name S T COIF I - .2 2 S/ <br /> ,t1 Phone <br /> Address _6BlO �• /'ru H• �+ City Sfl7G� <br /> Contractor's Name �N 7c�G� License# I�9/6S Business Phone_ 3718.232 r <br /> Contractor's AddressEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo �ox <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION W <br /> WELL CHLORINATION ElWE WELL ABANDONMENT ❑ OTHER El PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy , <br /> Sewage Disposal Field Cesspool/Seepage Pit Other { <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE ' TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ' <br /> i ❑ DOMESTIC/PRIVATE , `F r DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC X DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GR PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> El DISPOSAL I OTHER Other Information <br /> GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Dane <br /> PUMP REPAIR: I. ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth .SO fTt <br /> Describe Material and Procedure 4o, <br /> I hereby certi#y, that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws;: nd rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> 1 permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> N <br />` I ill all f Grout Ins ctio or to grouting and a final inspectio . <br /> _ <br />€ Signed X �- I• Title: Date: `gyp' V 2. <br /> I� (Draw Plot Plan on Reverse Side) /3 <br /> 6Glf?6 � �Si Isv// <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Applicationl <br /> Accepted By �`^ 1 Date 5- <br /> I Additional Comments: I�� <br /> Phase 11 Grout Inspection a III Final Inspection <br /> Inspection By 'I Date Inspection By Date ` ) <br /> Fee Is Due: ❑ ANNUALLY <br /> I,�.❑ PER UNIT El PER SITE 1:1 EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE I� EXPLANATION DATE DATE REMITTED AMOUNT DUEHECKAMOUD <br /> FEES yl <br /> LESS lyi <br /> PRORATION II <br /> PLUS <br /> PENALTY <br /> i OTHER II <br /> OTHER <br /> 1� ` ��- 1s <br /> Received by Dat IY Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />