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ocationWilrg <br /> Will Be Procpefssed Submitted Properly Completed. Be Sure To Sign The Application. ' <br /> FOR OFFICE USE: AUGU il 981 APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) 9/ <br /> SANt1�'�VIRONMENTAL <br /> PUMP&WELL <br /> HEALTH DjS,�,RR HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work.herein described.This application is <br /> made in compliance with Sanoaquin County Ordinance NQ.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address +� 41 � L, T'ry City/Town <br /> Owner's Namelnuts Phone <br /> Address S7?, City M Q <br /> Contractor's Name T y-e C 4- S � _ License# Business Phone <,/j— '�j 44 71 <br /> Contractor's Addri�"t;9 RYS1e4- t-a 64 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL V�— DEEPEN ❑ IJ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Q'' PUMP REPAIR 11 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank / S 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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �d <br /> M_bOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing fJ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION U-FCOTARY Type of Grout ^Z < <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Cpry^+d$�yd• Sptisy <br /> Type of Pump 'S',I H.P. + <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth .9 <br /> Describe Material and Procedure <br /> 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 /> 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 for which 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. <br /> Signed X Title: ��i��lett r� �" Date: �9 <br /> (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date a C/ <br /> Additional Comments: <br /> �JGOul nspection Pha a II fin I Inspection <br /> Inspection ByDate Inspection By 4i1 Date. y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January1 &Received 6 January 31`� - <br /> y ry ❑ July b&Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received "RETURN <br /> ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICAOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />