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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLIG��4,TION <br /> . (For Non-Transferable, 111 lcable,Suspendable) /) <br /> C <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) 1-7 3ffg Z. WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto 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 �Oaquin Local Health District. <br /> Exact Site Ad ��['s <br /> dresserf/! ?,Ai ��leak_/° gyri �_1} 11-r, Al City/Tow/nn 0 <br /> �/A' <br /> Owner's Name v'!t/ f_O S' Phone <br /> i Addressq City <br /> A+ rr S72r C�l]Z' <br /> Contractor's Name License# ;tZ-74i-/41/Business Phone 3 <br /> Contractor's Address Emergency Phone <br /> P Is Certificate of Workman's Compensation Insuranc on File With SJLHD7 Yes No <br /> j TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION n— PUMP REPAIR❑ <br /> 1 REPLACEMENT❑ <br /> l DISTANCE TO NEAREST: Septic Tank Sewer Lines _ �'L�a °r�.� Pit Privy <br /> Sewage Disposal Field M-4 Cesspool/Seepage Pit YA�o� Other <br /> Property Line Private Domestic Well lEoel—A- .Public Domestic Well <br /> ! INTENDED USE TYPE OF WELL <br /> F <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 92-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat - ` <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ` ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 4rs l �- <br /> Type of Pump H.P. <br /> E PUMP REPLACEMENT: ❑ State Work Done <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 /> 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 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." J <br /> I will call for a Grout Inspection prior to grouting and a final inspection. 1 <br /> Signed X LTitle: __ Dater l <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 2 _ <br /> Application Accepted By ��— Date <br /> Additional Comments: <br /> 1 Phase tl Grout Inspection P seeaal,l FiI I Inspection <br /> Inspection By Date Inspection By ��" — Date <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I B - REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DA REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 1S4S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> E OTHER <br /> OTHER <br /> 34 -- <br /> Received by Date Receipt No. Permit.No. Is ante D to Maileo Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '`1601 E.HAZELTON AVE.,P.O.Box ROD9 STOCKTON,CA 95201 <br />