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Applications Will Be Processed When Submitted Properly Complet ; e is igi:i6Tlk AW01 cm. <br /> FOR OFFICE USE: t APPLICATIONt - <br /> _ <br /> (For Non-Transferable, Revocable,Suspesn abM U 4 23 198 <br /> PUMP 8,WELL '1 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JOAQ UIN�L IOCAL <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/o l; &Td1A$T1Wlh`dbscribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San. <br /> ctaquirrj��LL,ocal Health District. . <br /> Exact Site Address <br /> 9922 Davis Rd. City/Town L©c on <br /> IZZ <br /> Owner's Names Dame E'riT118 PvletS er Phone 951-9998 <br /> Address City= o on _ r�f� <br /> Contractor's Name Sustefns, License# Business Phone <br /> Contractor's Address Emergency V t <br /> 4243 Cherry a- d Ave. Emer enc Phone same <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property.Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 11 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 11 <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 d <br /> ❑ GEOPHYSICAL , Moorman r Su f cdet2al IngtallO 1 <br /> PUMP INSTALLATION: Contractor � I <br /> T pe of Pump installed blleder valve in.p.discharge column <br /> 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 /> 1 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the.work for which this permit - —- <br /> r. is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br />'.r Contractor's hiring or sub-contracting signature certifies the following:-i certify that in the performance of the work for which this <br /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." 7i <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> b-�¢- <br /> Signed X _ w v Title: — Date: <br /> (Draw Plot Plan on Reverse Side) <br /> R D PARTM NT USE ONLY <br /> PHASE I 6/1_) <br /> 3 �p <br /> Application Accepted B Date <br /> PP P Y <br /> i <br /> Additional Comments: <br /> Pha e I Grout Inspection Ill F al Inspection <br /> Inspection By S77-7 <br /> e Date Inspection By 7 Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 ❑ July 1 &Received By duly 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ` <br /> DATE DATE REMITTED ` AMOUNT <br /> FEE <br /> LESS <br /> f PRORATION <br /> I PLUS _ <br /> 1 <br /> PENALTY <br /> 4 <br /> OTHER <br /> I OTHER <br /> �3 <br /> - Received by - Date Receipt No. Permit 0. Iss ante 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 />