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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> �Vk ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> 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. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 5762 E. Aeorn City/Town Stockton <br /> Owner's.Name �im Fir T i 11 i P Ha7,arrJ Phone 951 —8i 27 <br /> Address 5762 R- -A-cr)= City stnc�kton <br /> Contractor's Name C1 ark WP_1 1 & Entti-nmPnt License#371560 Business Phone 462-5597 �= <br /> Contractor's Address 2024 E, cha-rt2-r Way Emergency Phone nT t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Cr <br /> TYPE OF WORK (CHECK): NEW WELL Q DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR Q <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank +100 Sewer Lines Pit Privy <br /> Sewage Disposal Field +100 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 9.2��,L8t' <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 8 %ZR" <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . 125 Steel <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal KCl <br /> ❑ CATHODIC PROTECTION )gX90TARY Type of Grout k mix(C9'Yld.Q GOMent) <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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. <br /> Home owner sed a nature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issue shall not oy a erson in such manner as to become subject to workman's compensation laws of California." <br /> Co actor's h' ' r -contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> rmit is is all employ persons subject to workman's compensation laws of California." <br /> 1 w't call ction prior to grouting and a final inspection. <br /> Signed XTitle: Rui der- It nevelommntDate: 11 Ont 1982 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> P SEI �/ IA2_ <br /> �(. � <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase Grout Inspection Phase Ii Final Inspection <br /> ��' Date � Inspection B Date <br /> Inspection By /✓ � P Y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />