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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> - LSE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joag n County Ordin nce No. 1862 and thee rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �' `Yy I C�� j'a Z�j a' � l oT 3-7 City/Town -�Ttllfkr40 11 <br /> Owner's Name �'�1 s 62M & Phone � � 0 .3 5�3 <br /> Address Z City STDCi:!:�Mn <br /> Contractor's Name s Licese#,� _ Business Phone9V _. eW 7 <br /> Contractor's Addresses r�mpaf- Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL..p DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> / <br /> DISTANCE TO NEAREST: Septic Tank L6 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 0'5 t Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 71 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing if <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ra1 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout V14 i� <br /> ❑ DISPOSAL ❑ OTHER Other Information �r <br /> ❑ GEOPHYSICAL Surface Seal Installed By: C 1 <br /> PUMP INSTALLATION: Contractor R11AA 0 Ce --ruc <br /> Type of Pump P ravy,9444Z 3.0 40 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ala <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter f f Approximate Depth 16b <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X f�yL �d 22Z4 Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Ph M Grout Inspection R e I Final Inspection\o_�_�� <br /> Inspection By Date "� Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu nce 0ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9-5 <br />