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Nom ' <br /> Applications I Be Processed When Submitted Properly Completed. Be Su ' <br /> ca on. <br /> FOR OFFICE USE: APPLICATION - <br /> s ' (For Non-Transferable, Revocable, Suspendabfe) S E P 22 1980 <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> SAN QQJG�I�]J�IN LOCAL <br /> Application is herebymadetvtheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstallthew�ork LTH PISTbRdChisapplicatian_is <br /> made in compliance with San Joaquin County Ordinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact.Site Address lci SK A VA, City/Town 2 Dti <br /> Owner's Name � (I Z —SUVA c:r Phone Ct is 713 7 <br /> Address City <br /> Contractor's Name 7 i2 t � _ License#� — Business Phone 0^7 ^y t <br /> Contractor's Address tw3 ib 14"",L) _ Emergency Phone Q <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORT( (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT V <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> sewage Disposal Field Cesspool/Seepage PitOther - <br /> Property Lure Private Domestic Well 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 ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ® State Work Done " <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. T� f <br /> Homeowner or licensed agent's signature certifies the following."I certify that in the performance of the work for which this permit 1 <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 employ persons subject to workman's compensation laws of California." 7 <br /> I w' c 11 for a Grout Ins a do r to grouting and a final inspec <br /> Signed XTitle: - - ... .� <br /> Date: <br /> (Draw Plot Plan on R verse Side) <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE [ ' <br /> Application Accepted By V6 Date 9 <br /> Additional Comments: <br /> Inspection <br /> Phase II Grout Inspection ytrKase III Final Inspection <br /> By Date Inspection B ' Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACH ❑ January 1 &Received 8y January 31 -❑ July 1 &Received By July 37 <br /> MLANATION BILLING REMITTANCE $ REWT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED �. <br /> FEE AMOUNT <br /> LESSPRORATION <br /> PLUS <br /> PENALTYOTHEROTHER <br /> Received by - Date Receipt No. Permit No. - Issuance tate Mailed <br /> - Delivered <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 952f <br />