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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 1o1� <br /> FOR oF1=1cE USE: APPLICATION a -42, <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> 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 thework•herein described.This appiication is <br /> made in compliance Ith San Joaquin CountyOrdinanceNo. 188 2 and the r les and regulations of the San Joaquin Local Health District. <br /> Exact Site Address es [fit e-� ��1� b' � � -�r� �� City/Town '577j)c <br /> 01" G PILL e-T <br /> Owner's N ie S Phone fir. <br /> Address .. City S Y�✓�� 4 <br /> Contractor's Name r' License Business Phone a(, C? 00 <br /> Contractor's Address l Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE Of WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION El DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION R PUMP REPAIR❑ <br /> t <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ,/�� Sewer Lines Pit Privy <br /> Sewage Disposal Field lid Cesspool/Seepage Pit Other <br /> Property Line�� J Private Domestic Well A Public Domestic Well <br /> 1 t •_ <br /> INTENDED USE TYPE OF WELL f , <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> f DOMESTIC/PRIVATE ❑ DRILLED _ '"Dia.-of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing '21- <br /> ❑ IRRIGATION 11 GRAVEL PACK Depth of Grout Seal ,v <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 95 K _�5- a ` - <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL / Surface Seal Installed By:,� 4h na <br /> PUMP INSTALLATION: Contractor a / • "'��- 1 ' ry <br /> —Type of Pump �Fi:P... <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 /> 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 which this permit <br /> is issued, I shall not employ aiperson in„such manner as to become subject to workman's compensation laws of California.' <br /> Contractor's hiring or sub-contracting sig nature,certifies the'folIowing:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ personstsublect°to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior tog uting and a Iii <br /> inspection. t <br /> t Signed X A 4Ll _ Title: lr�n - / 2Gej in P Date: <br /> 1. 1 (Draw Plot Plan 'on Reverse Side) <br /> I^ t } FOR DEPARTMENT USE ONLY V <br /> µ <br /> F PHASE I :"�'-t "'�-' <br /> 10 <br /> i Application Accepted By " <br /> ~� r �Y- Date <br /> Additional Comments: <br /> 4 f - ha�II Gr t Inspection Phas 11 Fin;}I Inspection <br /> Inspection 8y �Dte � Inspectony' -Date '����- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By'January 31 ❑ July 1 &Received By July 31 <br /> _. BILLING REMITTANCE $ I REMIT <br /> _. BASE EXPLANATION AMOUNT DUE CHECKED <br /> • - -- - DATE DATE REMITTED; AMOUNT <br /> FEE ��– <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> , -OTHER <br /> Received•bywDate Receipt No Permit No. - Issbance Di -Mailed <br /> 1601 E.HAZELTON AVE.,P.O.Box 2999 5TOCKTON,CA 95201 <br /> Delivered <br /> .APPLICANT—RETURN ALL COPIES-TO; ENVIRONMENTAL HEALTH PEAMIT/SERVICES - <br />