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Mrd. Applications Will Be Processed When Submitted Properly Completed. Be Sure o 3i n The Application. Y <br /> FOR OFFICE USE: APPLICATION -" p� <br /> (For Non-Transfera&, Revocable,Suspendable) <br /> i <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This applicatio s <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 570 E S/I"416_ /2D _ City/Town qtr' <br /> Owner's Name Aff4ele. Zlds7e_ Phone 3/ /105 <br /> Address S 4 4F /fi,+/« gyp• cityTx r 4e' <br /> Contractor's Name 1:!:51j�pttf_ (,f/ �,Q �,1�-C� License # 7P8��Business Phone 7 S--1-3372 <br /> Contractor's Address Emergency Phone 7 S f-- 3 4-sr <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X — No <br /> TYPE OF WORK (CHECK): NEW WELL P DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR N <br /> REPLACEMENT❑ Qp <br /> DISTANCE TO NEAREST: Septic Tank S4 __ Sewer Lines Pit Privy <br /> i Sewage Disposal Field Cesspool/Seepage Pit Other --�- <br /> Property Line '��3d9 Private Domestic Well�� Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation 42 /1=7-9257` 6z7 <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Q <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> ❑ OTHER Other lnformation <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> a15 <br /> tV r <br /> Type of Pump <br /> H.P. <br /> 0 I <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' <br /> 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 1 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the foliowing:"I certify that in the performance of the work forwhich this permit F <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 orsub-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." r <br /> I wip call for a Grout Inspection prior to grouting and a final inspection. �) <br /> Signed Xoe <br /> Title: Date: <br /> _49 <br /> �—�Q t <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPARTMENT U E ONLY <br /> PHASE I <br /> Application Accepted By d , <br /> Additional Comments: Date 1,2— 9—i- <br /> d <br /> cl <br /> Phase II Grout Inspection u' � ' <br /> Phase III Final Inspection <br /> Inspection By 7, Date /IF' "'f-9' Inspection By Date w <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> _ BASE EXPLANATION BILLING REMITTANCE § REMIT <br /> DATE AMOUNT DUE CHECKED <br /> DATE REMITTED <br /> FEE ' AMOUNT i <br /> LESS <br /> PRORATION <br /> PLUS ' - <br /> PENALTY, <br /> 5 <br /> OTHER <br /> OTHER r <br /> Received b <br /> Y Date 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 ,STOCI(TON,CA 95201 <br />