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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> h =,FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> t ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 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 <br /> made in compliance with San �Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Lpo cal Health District. <br /> Exact Site Address 3�.. � CA t2_1? F, T-f ft- �ri W City/Town �7���/st f�r� <br /> Owner's Name r'�R� ka w I.&,i Phone <br /> Address - � City—:5, � C&'7-a 0_a' <br /> Contractor's Name Y� u License#�� Business Phonett-ell Q <br /> Contractor's Address _l/ L^ �v r' �b f_ _Id Emergency Phoney <br /> Is Certificate of Workman's Compensation Insurance/n File With SJLHD? Yes / No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ - OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT °©-~' I <br /> � DISTANCE TO NEAREST: Septic Tank � Sewer Liness' '' Pit Privy <br /> I Sewage Disposal Fie d u 'f Cesspool/Seepage Pit Other <br /> i Property Line no Private Domestic Wel{ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 13CABLE TOOL Dia. of Well Excavation <br /> 1 A DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> C ❑ DRIVEN Gauge of Casing G <br /> 11 IRRIGATION El GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor_ I{J1 i t/ Al a c! f_u Q/J/-4 <br /> r Type of Pump -eiil ce -_ H.P. P <br /> PUMP REPLACEMENT: R-State Work Done (VA- <br /> PUMP REPAIR: ❑ 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 <br /> k 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:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of-California." <br /> t I w'I call for a Grout Ins ct' n prior to gr uting and a final inspe 'on. <br /> Signed X : - Title: at.: <br /> ]S Z-3 <br /> (Draw Plot Plan on everse Side) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> r Application Accepted By Date <br /> Additional Comments:' <br /> I 'Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By -.-+ -. s .. ... -- Date Inspection By Date <br /> f Fee Is Due: ❑ ANNUALLY ❑ PER UN1T ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> } - BASE EXPLANATION AMOUNT DUE CHECKED' <br /> - DATE DATE REMITTED AMOUNT <br /> FEE )�{y VW.0,%A :.-'-`.f„r' � <br /> LESS ^K - <br /> 1 PRORATION <br /> PLUS <br /> i -PENALTY- " - ' <br /> OTHER <br /> OTHER <br /> It �7 ci�G = kW <br /> Received by _ •-Gate. Receipt No _.y,.,-.f` P rmit NG- I tuancelDate .Mailed Deli red <br /> APPLICANT—AETURN ALL COPIES TO: (ENVIRONMENTAL"HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo■2009 STOCKTO ,CA 95201 <br />