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c 1iBPPrgced Submitted Properly Completed. Be Sure To Sign The Application.1 <br /> �- reCE usE: APPLICATION _ <br /> EP 8 19$1For Non-Transferable, Revocable,Suspendabte) / PUMP&WE L } <br /> ! / ' <br /> EIUVIRONMENTAL HEALTH PERMIT 4 <br /> LOCAL <br /> (COMPLETE IN TRIPLICAC�{�){J`,�: I � ICTRICT WATER UALITY. ., <br /> Application is hereby made to t ttoagtlin Focal Health District fora permit to construct and/or install the work herein described.This application is <br /> made incompliance with San.Joa qi Uin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 4315 Ni eiryland' Ave. - 'CityiTown "Stockton 1� <br /> r Frank �CTaylor, �: Phone 477-0592 <br /> Owner's Name �- }� <br /> Address 4444 Dorset .Ave. city Stockton, . 411 <br /> Contractor's Name MOOrmaillt s Water-:Systems '' License#•267696 ;} Business Phone 931-321.0111 <br /> Contractor's Address 4243 Gherr° land Ave. "* Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> _ _ 1. -. <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR o <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Se tic an Sewer Lines Pit Privy v <br /> ..:,+=Sewage Disposal Field Cesspool/Seepage Pit Other— <br /> Pr.perty <br /> therProperty Line Private Domestic Well Public Domestic Weil II <br /> C <br /> ENDED USE µ TYPE OF WELL <br /> I STRIAL ❑ CABLE TOOL Dia. of Well Excavation STIC/PRIVATE ❑ DRILLED Dia- of Well Casing STIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> Y111 ATION I ❑ GRAVEL PACK ; Depth of Grout SealODIC PROTECTION ' ❑ ROTARY " Type of Grout <br /> SAL ❑ OTHER Other InformationHYSICAL Surface Seal Installed By:STALLATION: I Contractor � <br /> M <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done t �� <br /> PUMP REPAIR: State Work Done chlorinate well and seal <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth IM` <br /> Describe Material and Procedure I� <br /> Ip <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> +ordinances, state laws;and rules and regulations of the Sari 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 whicfitthis permit <br /> z is issued,"I shall not�I�nploy any person in.such manner as to become subject to workman's compensation laws of(California." <br /> Contractor's hiring or' <br /> sub-contracting signature certifies the following:"I certify that in the performance of the.work for which this <br /> f permit is issued, i sh aN employ persons subject to workman's compensation laws of California." <br /> I will call forGrout Ijnspection prior to grouting and a final inspection. ` <br /> Signed X I Title: ryr�l� Date: <br /> (Draw Plot Plan on Reverse Side) �— I�I <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: I`MI <br /> Phle II Grout Inspection Phase III Final Inspectional <br /> ' Inspection By - K I rl Date Inspection By Date <br /> t <br /> w _ Fee Is Due: 11ANNUALLY �M -❑ PER UNIT ' El-PER SITE 11EACH ❑ January s &Received,B Ja dry 31 ❑ July! I�IReceived By July 31 <br /> p BILLING REMITTANCE $ REMIT <br /> BAST' EXPLANATION DATE DATE REMITTED AMOUNT DUE ;` CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ,9 J <br /> OTHER <br /> OTHER <br /> IPI <br /> ++Received by -Qat@- -^-^ - Receipt No. - - - Permit No. _ suance ate Mailed Delivered <br /> f 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> _%_. Ii! 'IM <br />