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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) <br /> PUP,/IP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 <br /> made in compliance with San Jo quin Co my Ordina ce N 1862�d tt�e rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address nM4 � WET® w�99 City/Town �OQ/ , x%19-' <br /> Owner's Name 7P'hA he 70 73APS CO. ac CA-e-r F Phon47,;44—:27 <br /> Address 774�* I M" 7 '577' City Contractor's Name U b(lEZL 'PAU4clG License#34"W2— Business Phone 7 3 37 <br /> Contractor's Address :Fe? 50.< 3 Emergency Phone 76V—3 4 Cfn, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes- No �/t <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION E]WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other L <br /> Property p y Line3® Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> Xr DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 0 �, <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 4"V Lam' <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 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 wiill c <br /> /►�al. or a � In�tion prio to grouting and a final inspection. <br /> Signed X /A Title: C Date: Co-1�Q3G� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i Q_ <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phas 111 Final Inspection <br /> Inspection By Date — Inspection By A - Oate 1,—ala— <br /> Date. <br /> Fee Is Due: ❑ ANN LLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1!8 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 �+ l <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � X40 <br /> Received by Date Receipt No. Permit No. I Issuan a 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 />