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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. / <br /> FOR C AJSE: APPLICATION <br /> r (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&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 with San Joaquin County Ordinance No. 1 8 and the rules and reg ations of the San Joaquin Local Health District, <br /> Exact Site Address City/Town �S-C 4lr f <br /> Owner's Name 41,y " Phone w <br /> Address P [►!1• '- t7" City <br /> Contractor's Name/* 1CBY1se fin Business PhoneC� ��!� <br /> y Contractor's Address _� ergency Phone — a <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> F TYPE OF WORK (CHECK): NEW WELL®-- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION C�1— PUMP REPAIR C3 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines -- Pit Privy <br /> ' Sewage Disposal Field/O d �4 Cesspool/Seepage Pit ./f/� Other ` <br /> ` Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> M--5-0-MESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing GC <br /> El IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal O <br /> ❑ CATHODIC PROTECTION EF'ROTARY Type of Grout GFS C <br /> ❑ DISPOSAL ❑ OTHER Other Information _. _ �Gn4 --^ --Z^G <br /> ❑ GEOPHYSICAL Surface Seal Installed By:ef:2 . 051 !/(fiC • \ <br /> PUMP INSTALLATION: Contractor S M C. <br /> Type of Pump- H.P. 2 U <br /> PUMP REPLACEMENT: ❑ State Work Done Nr <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 <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." <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 e I y persons subject to workman's compensation laws of California" <br /> ill call for a Gro t I pe 11 prior to routing and a final inspection. <br /> i l � <br /> I Signed X ! Title: a Date: a C� <br /> (Draw Plot Plan on Reverse Side) <br /> /FODEPAR MENT USE ONLY <br /> k PHASE <br /> ' Application Accepted By J d 6 Date <br /> Additional Comments: _9�zd <br /> P ase II Grout Inspection Phase III Final Inspection <br /> Inspection By. Date 4-6--90 Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 14 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 REMIT <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED �J AMOUNT <br /> FEE C!I - <br /> LESS <br /> PRORATION <br /> PLUS. <br /> PENALTY <br /> ` OTHER <br /> OTHER <br /> cv— <br /> Received by Date Receipt No, Permit o. Issua ce Date Mailed Delivered <br /> F <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,�, --1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA , <br />