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f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.'FOR OFPIICE USE: APPLICATION }"-- <br /> 10-41 <br /> ek (For Non-Transferable, Revocable,"Suspendable) PUMP&WELL <br /> t ENVIRONMENTAL' HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER,QUALITY <br /> .•. ;.....s " r fir` s:PA ' +' <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 with.San Joaquin County Ordinance No. 18622 and a rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address- �I� �' t City/Town ` t <br /> I _ ,/ <br /> Owner's Name _'- .. �'°y'� . � CI. ►e' ���' Ph'one <br /> Address ln.S�7y '"_ ri.t,/- City .1 k ' <br /> Contractor's Name +0&J Q: fk1 E ""License#"-/23p73,:�—Business Phone__ 4 62 r 7-A74- <br /> Contractor's Address Rbli Emergency Phone `` T <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No / <br /> TYPE OF WORK (CHECK) NEW WELL❑ DEEPEN ❑ PRECONDITION❑ DESTRUCTION❑ / <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Ir <br /> I DISTANCE TO NEAREST: Septic Tank' y Sewer Lines Pit Privy <br /> Sewage Disposal Field `_ --.-�Cesspool/Seepage Pit Other <br /> Property Line Private DomesticrWell xV Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑-CABLE TOOL Dia, of Well Excavation <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 ±' y ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL { Surface Seal Instal le By: <br /> PUMP INSTALLATION:' [ Contractor � ` _ <br /> Type of Pump -77M✓ ter H.P. <br /> PUMP REPLACEMENT: i � +❑ State Work Done <br /> PUMP REPAIR: . ,�,;, ,, State Work Done <br /> J._ <br /> DESTRUCTION OF WELL: Well Diameter " Approximate Depth <br /> " --mZr 4 '- Describe Material and Procedure <br /> 3 I hereby certify that I have prepared this application'and that the work will be done'in accordance with San Joaquin County _ <br /> } <br /> 'ordinances, state laws,"and rules and regulations of the San Joaquin Local Health District. a � ^ <br /> --Homeowner or licensed agent'ssignature 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 fcrwhjch this <br /> permit is issued, I shall employ persons subject to,workman's compensation laws of California." <br /> I will call for a"Grout Inspet7,nD <br /> g Td a final inspection." <br /> SignedWi&- .. iile: �,eJ Date: <br /> ot (Draw Piot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accept By - Date -&1 <br /> Additional Com_me t <br /> Phase II Grout Inspection - Phas fl Final Inspection .i it <br /> Inspection By Date `--Inspection By �. Date <br /> q &2- <br /> t i <br /> Fee Is Due: ❑ ANNUALLY El.PER UNIT O'PER SITE ❑ EACH ❑ January 1-&Received By January 31 ❑ July 1 &.Received By July 31 <br /> REMIT <br /> BILLING - REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE k <br /> LESS ` ' - t r <br /> PRORATION <br /> 'PLUS - <br /> PENALTY - - - - <br /> OTHER + <br /> ' r 1 <br /> OTHER _ + <br /> t <br /> -Received by Date Receipt No. - - Permi No. Issuanc Date-- _ Mailed -Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA$5201 <br />