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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FarFFICE USE: APPLICATION!?t <br /> (For Non-Transferable, Revocable,Suspendable) �j j <br /> �.. <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 I <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa uin Local Health District. <br /> Exact Site Address y�a.�` A a([7 Cid lZ City/Town St 11 <br /> Owner's Name -s+e I,te A4n A Phone � � j7^1 7 I <br /> Address City <br /> Contractor's Name s License#3Y�4�Y Busin/ess Phone <br /> Contractor's Address 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 ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank AZ Sewer Lines Pit'Privy <br /> Sewage Disposal Field If Cesspool/Seepage Pit Z,50 Other <br /> Property Line - Private Domestic Well Public Public Domestic.Well. <br /> INTENDED USE TYPE OF WELL /�/i <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> f/ <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ` <br /> ❑ DOMESTIC/PUBLIC y - ❑ DRIVEN _ r.' Gauge of Casing z <br /> ❑ IRRIGATION _ ❑_GRAVEL PACK "f DepthRof Grout Seal <br /> 11CATHODIC PROTECTION _ ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL' ❑ OTHER Other Information Wj <br /> ❑ GEOPHYSICAL Surface Seal Installed By: rf 1 <br /> PUMP INSTALLATION: Contractor rdh 1564 ,S <br /> t; Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done_ <br /> PUMP REPAIR:F ❑ 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performahce of the work for,wliich 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 /> J 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 In pectign prior to grouting and a final inspection. fix. <br /> Signed X Title: r9 Date: <br /> 1 (Draw Plot Plan on Reverse Side) <br /> t r <br /> FOR DEPARTMENT USE ONLY <br /> PHASEIq jJ <br /> Application Accepted By Date d 7 <br /> 1 j <br /> Additional Comments: <br /> Phase II Grout Inspection Ph se III Final Insvection <br /> Inspection By Date Inspection By Date 4— e2 "'9�6- <br /> .Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PUPER SITE ❑ EACH ❑ January 1 &-Received By January 31 ❑ July 1 &Received By'July31 f <br /> REMIT <br /> BILLING REMITTANCE $ 1 <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED t. <br /> F ('� AMOUNT <br /> FEE d <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - ^ <br /> 1 <br /> 117/71 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.-HAZELTONAVE.,P.O.Box 2009 - STOCKTON,CA 95201 _ _, <br />