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Applications Will Be Process; Wien Submitted Properly Completed. Be Sure To Sign The Application. <br /> - T�@FFICE USE: APPLICATION _ ` / j <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT{" W <br /> (COMPLETE IN TRIPLICATE) 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 N <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin ocal Health District. <br /> 0 <br /> Exact Site Address 0_34v/ CQ 101 zw L_ Ro A O� _ City/TownIF r <br /> Owner's Name dice R I ry 0 Phone <br /> Address 3 AW e2. 04 4 R/Wto � CityTme_!r ,?JV r� <br /> Contractor's Namevv,-,/l�Srl�4 (�U�r.� r�r.� icense# d? Business Phone <br /> Contractor's Address/ a'0 Emergency Phone _ G 6f _�'_3. <br /> Is Certificate of Workman's Compensation Tisu ante on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTP — <br /> DISTANCE TO NEAREST: Septic Tank &-e A0 (' 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> A'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor 1,1A.1 I vri ,e e <br /> Type of Pump 7C,A AP we H.P. aZ <br /> PUMP REPLACEMENT: $'State Work Done e_�Alileo;� /=an-t ! 15' O oe 7V 1&4? ly"'e <br /> PUMP REPAIR: ❑ State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth "tt <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will tali for a Grout Il tion prior to grouting and a final inspecti <br /> Signed X / .� Title: Date: <br /> (Draw Plot Plan on Re erse Side) <br /> FOR EPART USE ONLY <br /> PHASE <br /> Application Accepted By TM Date ?� <br /> Additional Comments: <br /> Phase II Grout Inspection Phas III Final Inspection <br /> Inspection By Date Inspection By ate <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ae <br /> LESS <br /> PRORATION41 rp <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7;V 71 <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 />