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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F�,,OR-OFFtCE USE: APPLICATION <br /> (For Non-TrSnsferable, Revocable,Suspendable) •� <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San.Joaquinj..9cal Health District. <br /> Exact Site Address �—. ///z Ael City/Town <br /> Owner's Name 43u 4/C Phone <br /> Address �3 t' �� TIZ �v�„ City <br /> Contractor's NameLicense#377-7$S Business Phone 2.Ocl- 7 <br /> Contractor's Address -?r-> el'o X Emergency Phone /� l <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes>�- No <br /> TYPE OF WORK (CHECK): NEW WELLO DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ .-- <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /o p Sewer Lines 57,:o 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 f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation /0 1�- <br /> /�DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /o G�" <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal s'ti' <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <FScams <br /> ❑ DISPOSAL ❑ OTHER _ Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Gy//T2A731� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 6' Approximate Depth Zy� <br /> Describe Material and Procedure Z-L <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 cz <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a rout Inspection prior to grouting and a final inspection. <br /> Signed X/ <br /> ,;III <br /> Title: 2. <br /> -�--107 Date: — <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE <br /> Application Accepted By -A c-c.— 0 73 Date <br /> Additional Comments: <br /> -� <br /> I,�Phase 11 Grout Inspection / Phase III Final Inspection <br /> Inspection By?^� r-- 3.- - Date ;4,IE _ Inspection By Date /3 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> �n fl <br /> FEE �(�( �-� R© _ <br /> LESS U V (J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> `-m -7 `7 7 u <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 />