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r <br /> I , — Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ; ,- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or.install the work herein described.This application is <br /> r 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 4915 E. Cherok .& kA2 City/Town nr. ton <br /> Owner's Name Arnold F, Mai^v (';;V;;I i Phone <br /> Address City' <br /> Contractor's Name _Moo r[f41T1 S, wa�tAr' Sy6teinSL License'#?�7�QF Business Phone ..937.-3210 <br /> Contractor's Address 79 7fl [ i 1 anv Irl _ Emergency Phone v) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLFiD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENTS OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ r <br /> REPLACEMENT❑ <br /> DISTANCE TO{NEAREST: Septic Tank Sewer Lines Pit Privy i <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> Y INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL - ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTiC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL., ❑ OTHER Other Information rn <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> I PUMP REPAIR:, ❑ State Work Doe _ <br /> DESTRUCTION OF WELL:. ,Well Diameter �'' "" r Apr xlmate Depth <br /> Describe aterial and Procedure ^ � 1"d'LCf le ,� -� <br /> s( <br /> I hereby certify that I have prepared this application and that the k will be done in accorAancp with San Joaquin Co n <br /> r ordinances, state laws, and 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 thewvr forwhich this per, It � <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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. p <br /> Signed X �1���1'�^�7 Title: &2- �/1� Date: <br /> Plot Plan on Reverse Side) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I } <br /> Application Accepted 8 a Date 151�/-, <br /> f <br /> Additional Comments: <br /> PR NSe 11 GLut Inspection Phase III spection <br /> Inspection By Date Inspection By ate <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recei By January 31 ❑ Juiy 1 &Received By Juiy 31 <br /> s BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTER AMOUNT DUE .CHECKED <br /> AMOUNT <br /> FEE Q <br /> LESS <br /> PRORATION <br /> PLUS - - - . <br /> PENALTY <br /> OTHER <br /> OTHER <br /> .. Received by Date Receipt No. Permit No Iss ance D te- Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />