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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (C MPLETE IN TRIPLICATE) WATER QUALITY f f <br /> x <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This applicatilin is <br /> made in compliance with San Joaquin County rdinanc�No. Ind the rules and regulations of the San Joauin LocaJ H alth District. <br /> Exact Site Address -* / r P City/Town /cP h <br /> Owner's Name � � Q `r/� Y'Pi CC�✓`5 Phone >''` <br /> Address !/t!LE <br /> City i <br /> Contractor's Name License# Business Phone ' f <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 0�J4 DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ f <br /> WELL CHLORINATION ❑ WELL ABANDONMENTO OTHER ElPUMP INSTALLATION ❑ PUMP REPAIR F-1 4C11) <br /> REPLACEMENT❑ I� j <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> —,Sewage Disposal Field Cesspool/Seepage Pit <br /> g p .. .Other � <br /> Property Line Private Domestic Well I—N Public Domestic Well <br /> INTENDED USE TYPE OF WELL Gr+ Oma! .s1.ro - <br /> El INDUSTRIAL .: _❑.CABLE..TOOL,_.._, ,�,4,,.,_,,,-Dia. of Well Excavation �I <br /> ❑ DOMESTIC/PRIVATE-r .. --[].DRILLED- ,.�_� <br /> �. �,...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 <br /> Cl GEOPHYSICAL Surface Seal Installed By: a <br /> PUMP INSTALLATION: Contractor �} ; <br /> Type of Pump t H.P.W I <br /> PUMP REPLACEMENT: ❑ State Work Done # I <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 6 <br /> Describe M terial and Procedure e,A.,1 <br /> �ra.KIL <br /> c <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 /> i <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." j <br /> Contractor's hiring or sub-contracting signature certifies the4ollowing:"I certifythatin�the performance of the work for which this <br /> s issued, I shall tocompensation� law <br /> p y persons subject to workman's laws of California." , <br /> I will c for a Gro tin p coon prior to groutin and a final'i sn pe I ­�+�C� <br /> Signed X C_AC Titled � SS'►'. Grip-f Oate <br /> - (Braw=Plot-Pian-on-Reverse-Side) \Jf - f, <br /> F_ <br /> t FOR DEPART ENT USE ONLY <br /> PHASE I � f <br /> jt� &/4 <br /> . <br /> Application Accepted By. Date �� 79 <br /> Additional Comments: ` <br /> I<; <br /> Phase 11 Grout Inspection ! Phase II! F ectian' <br /> Inspection By _ m Il:' Date Inspection By ale 1= <br /> I T } <br /> Fee I9 Due., ❑ ANNUALLY ❑ PER UNIT ❑ PER`SIT�,P [TEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 � <br /> BASE ; EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOUNT DATE DATE REMITTED DUE CHECKED' <br /> AMOUNT <br /> FEE 3 '�a � -LESS . <br /> PRORATION <br /> PLUS <br /> PENALTYf <br /> OTHER I �; <br /> OTHER <br /> O l7 <br /> `79 ?-1 <br /> Received by Oate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> . .,. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />