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Applications Will Be Processed When Submitted Properly Completed. Be Sur T a SI Ttr7lication. <br /> FOR ICE USE: APPLICATIONCA <br /> (For Non-Transferable, Rev oca <br /> _ <br /> ENVIRONMENTAL HEA PER ' ly �gg�M1J_ PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALIT JUN <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or ins <br /> ot <br /> Nt"oILk00&&10described.This application is <br /> made in compliance with Soman Joaquin Count Ordinance No. 1862 and the rules and rertls�o t �� 4�$f Local Health District. <br /> Exact Site Address // -S.S .s G 14_u1 i4Et���wn <br /> Owner's Name ¢fti&e& -2-�: a,�� Phone <br /> Address >S ss_ City =r.{,"�s,�_ <br /> Contractor's Name License# a7,1 Business Phone <br /> Contractor's Address 10 05 2 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT ❑ OTHER 13R PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑^USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> U 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 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done -42A,01.? ��-- , � v_s ,rs��ZI! <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 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 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 CAI-k 3 ,�A6.,,,,4 .439 Title: 4V Date: <br /> (Drew Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I G "�4�� <br /> Application Accepted By W Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase III Final Inspection <br /> Inspection By Date Inspection By, "� Date —7—,2t:: i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE CJ + k 5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> 169 CfS <br /> Received by Date Receipt No. Permit No. Iss nce Obte Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />