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^ .. Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR R OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT 1110,&J �ti��YcGc-p <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin LocalHealth District for a permit to construct and/or install thew ork herein described.This application is <br /> made in compliance wit SanJoaquin C �OrijnaPce No.1862 and the r les and regulations of the San Joaquin Local Health District. <br /> Exact Site Address. or, - City/Town <br /> Owner's Name -/�'t Phone .2�c1 ��,�' <br /> Address ./ 2-Ge—^- City <br /> r �ense# f '�` ��F-- /! 7597 <br /> Contractor's Name �/1�L Q t/tr•�, .!-G�Ly} �••1�1�. Business Phone <br /> Contractor's Address A Emergency.Phone 1, , <br /> Is Certificate of Workman's Compensation Insurance on File With=-, D? Yes r No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ � I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ SG r <br /> I� <br /> REPLACE MENT.❑_�_. . ��s- .�� 1 _ <br /> DISTANCE TO NEAREST: SepticTank�Tl <br /> fi�Sewer Lines "P ti Privy~ �.�r/;L/ <br /> Sewage Disposal Fiel 4 OIJ4,45—_ Ce'ssp6o9ll/Seepage Pit �� u � ther <br /> Property Line -� nvate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE PQ�R ILLED Dia. of Well Casing IF <br /> ❑ DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 11ROTARY Type of Grou- <br /> ❑ DISPOSAL ❑ OTHER Other Information' <br /> ❑ GEOPHYSICAL Surface Seal Installed By: JIle Y-- _—0 <br /> i PUMP INSTALLATION: Contractor Y '� <br /> Type of Pump— �� �J�r� H.P. `-- • ' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: G " ❑ State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <br /> I hereby certify that I haee.,prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and 'rules?and' of the San Joaquin Local Health District.' <br /> Home owner,or licensed agent's signature certifies the following:1 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 forwhich this F. _ <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.' <br /> , r <br /> 1 will call for a Grout Inspection prior to grouting and a final inspection. 't r I r <br /> Signed X r Title: ' <br /> if -rs'r..-� Date: `S .s <br /> '(Draw Plot Plan on Reverse Side) <br /> ` FOR DEPARTMENT USE ONLY ' <br /> PRASE I �1 <br /> / � 7�S t <br /> Application Accepted By Date - <br /> Additional Comments: <br /> Phase II Gr i spection Phase III Final Inspection 1- <br /> t Cde <br /> Inspection By '�2 a' Date Inspection Date <br /> if <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received.By January 31 ❑ July 1 &Received By July 31 <br /> F REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $3 AMOUNT OUE CHECKED <br /> DATE DATE REMITTEDAMOUNT <br /> Jr <br /> FEE O <br /> LESS <br /> PRORATION <br /> PLUS 71 - l <br /> PENALTY - <br /> OTHER <br /> +s OTHER "".��QQ} - --- ,-. �- <br /> Received by I Date I Receipt No. Permit No. Iss ance ate Mailed_ Delivered <br /> * APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16o1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />