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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ­001 "OFFICE USE: APPLICATION a <br /> " (For Non-Transferable,Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT , 1 <br /> (COMPLETE IN4RIPLICATE) WATER QUALITY <br /> Applicatilimn Is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work hen at'ribed.This.application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Z A 0-.14 D . %14-e 64pe L&o G City/Town STOC-KTb/- <br /> Owner's Name 'ZOAle Phone �n�y-'�'l 3 l BEA 5ir►GSS <br /> AddressCity <br /> Contractor's Name A43i /+ii9id'S 'I sten ,5;j67Z A ' License 40 4 769 lei+ Business Phone fJ/_3,./o <br /> Contractor's AddressC&_& � 40 LCB)C9S;,1 9111`Drd Emergency Phone 73/—S,�Aid i0 <br /> Is Certificate of Workman's Compensationnsurance on File With SJLHD? Yes _ No h <br /> TYPE OF WORK(CHECK):~ NEW WELL. ..:. DEEPEN ❑ RECONDITION❑ .-- DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ - y . <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy -� <br /> A <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 2 _Private Domestic Well Public Domestic Well /J UytJR_ , <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_/,-.Q <br /> DOMESTIC/PRIVATEDRILLED Dia. of Well Casing 411 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /� y� 4 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal f " <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout a e m�nJ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: P-A met-0 li..d.;94 <br /> ).. <br /> PUMP INSTALLATION: Contractor O"rWater- , <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: El State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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:'9 certify that in the performance of the work for which this j <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> -• 1 w call for a Grout Inspection prior to grouting and a final inspection. <br /> ca ,� <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted B O Date ti- ; <br /> Additional Comments: <br /> P ase I Gro t Inspection as I F' I inspection <br /> Inspection By Date Inspection By ��� f%�'F`'� Date 7 �' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 11 PER SITE K❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT l <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE QO 41 <br /> Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER i <br /> Jr E q 13 L30 a'- f <br /> Received by - Date Receipt No.- Permit No. I Issuancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />