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id ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 2 <br /> ,~ (For Non-Transferable, Revocable, Suspendable) � <br /> ENVIRONMENTAL HEALTH PERMIT PUMA& tLl <br /> HY <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY j <br /> ApplicationisherebymadetotheSan Joaquin Local HealthDistrictforapermit toconstructand/Or install thework herein described.This application is + <br /> made in compliance with Pan Joaquin County Ordin nce No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> v <br /> Exact Site Address <br /> � City/Town/ <br /> Ow -17-r- <br /> neris Name Phone 7 7 - <br /> Ad d rens 6L <br /> City—,rV- '+ C../ L.J _ <br /> Contractor's Name _�G. e/14' _ sl1,ell ,L i�t/�j License# Ft <br /> I� 01I <br /> � .3 Business Phone 8" & 79 <br /> Contractor's Address a"oo� Emergency Ph <br /> g y one <br /> Is Cert ' �— <br /> iificate of Workman's Compensation Insurance on File With SJl HD? Yes No E` <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL�16HLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ f =-It r <br /> REPLACEMENT❑ t <br /> DISTANCE TO NEAREST: Septic Tank vAle, Sewer Lines XloAl1- Pit Privy <br /> rf' Sewage Disposal Field lViI.Aje Cesspool/Seepage Pit Other_ IJU <br /> � <br /> Property Line �f"�' Private Domestic Well O, �C, -' �'�_ Public Domestic Well__/JO A-�1E/ <br /> INTENDED USE TYPE OF WELL �� g <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ai� <br /> �OMESTIC/PRIVATE 11 DRILLED " Dia- of Well Casing !� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �a-4 fei <br /> ❑ IRRIGATION ❑ GRAVEL-PACK - - .,,._,Depth of Grout Seal <br /> ❑ CAITHODIC PROTECTION ❑ ROTARY Type of Grout n <br /> �l� �L!i <br /> ❑ DISPOSAL ❑ OTHER - Other Information <br /> ❑ GEOPHYSICAL Surface Seal Inst/alled B I_i l i'` <br /> PUMP 1"NSTALLATION: Contractor �Gt- / 1/1 <br /> ` l! <br /> Type of Pump !- H.P. <br /> F <br /> PUMP;REPLACEMENT: 11 State Work Done <br /> PUMP(REPAIR: ❑ State Work Done ~ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> IIIA 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 riot employ any person in'such manner as to become s0bject-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 1 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> it <br /> IIcall for a Grofi <br /> t Inspection prior•to grouting and a final inspection. <br /> i /} a <br /> Signedl..X � Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> I _r r FOR DEPARTMENT USE ONLY <br /> PHASE in� `. •'� ? y �".. k } <br /> Application1, Accepted By `\}'��}",'� — Date <br /> Additional Comments: <br /> Ph a Grout I pection ` P s III Final I pection <br /> 'I I Inspection By �/ ate 41 Inspection By Date <br /> Fee IS Due: ❑ <br /> AN ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31tl ❑ July 1 &Received By July 31 <br /> l REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> Y DATE DATE REMITTED 'AMOUNT - <br /> FEE <br /> Liss 4 <br /> PRORATION , <br /> �f <br /> PLUS <br /> PENALTY <br /> P <br /> OTHER it <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 />