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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ' <br /> FOR•mNFFICE USE: APPLICATION - <br /> C (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT RUMP&WELL <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 the work,herein described.This application is- <br /> made in compliance witli San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address r l� City/Town �G <br /> Owner's Name JS r� , Phone <br /> Address 441, /- -1,C417- ,4,>,4 ,E 042 <br /> City <br /> Contractor's Name GIZA ? /ELL -jL (�/�' 670 License# �G� Business Phone <br /> Contractor's AddressV1,4 y Emergency Phone r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes, _.` <br /> No j <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN 13 RECONDITION 11 DESTRUCTION 13WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank -7 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 3 <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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: R�.r <br /> PUMP INSTALLATION: „ Contractor C / ,� <br /> Type of Pump S 0Z H P pn <br /> PUMP REPLACEMENT. ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> it <br /> DESTRUCTION OF WELL:, Well Diameter-& Approximate Depth s I <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." l <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." <br /> laMrrot Insection p ' r to grouting and a final inspection. <br /> Signed X Title: V Date: t <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By C { Date ?� <br /> Additional Comments: <br /> Phase N Grout Inspection P s III F'r al Inspection c� _ <br /> Inspection By Date Inspection By Date T J 5 ` g <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Ot PER SITE ❑ EACH ❑ Januar 1 &Received 8 Januar 31 <br /> . Y Y Y ❑ July 1 8 Received By July 31 I <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE C7 9 <br /> LESS <br /> PRORATION <br /> PLUS <br /> E <br /> PENALTY <br /> - s <br /> OTHER - - <br /> OTHER79 S <br /> —1�_. 7 <br /> Received by 4 Date Receipt No. Permit No. Issuance Date Mai#ed Delivered <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES1 <br /> - - 1601 Ei RAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />