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Applications Will Be Processed When Submitted Properly Completed. Be Sur'�Slgn The Application. <br /> FOR OFFICE USE: APPLICATION � 1- <br /> J �gg� <br /> (For Nan-Transferable, Revocable,Suspendable) <br /> PUMP <br /> ENVIRONMENTAL HEALTH PERMIT SAN . r.+)-_, 4 <br /> h` Y"� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DIST.`1CT <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 C✓ouunty Ordinance No. 1862 and the rules and regulations of the-San Joa uin Local Health District. <br /> 1� <br /> Exact Site Address � q��l/P,�iV ' 1 �f City/Town 1 <br /> Owner's Name } 144 Phone <br /> Address City 41,1,/11 2!; /if I� <br /> Contractor's Name f' License#=��oBusiness Phone <br /> Contractor's Address d/9'y iii» G��i�ir/Y C-,+�� 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❑ I <br /> DISTANCE TO NEAREST: Septic Tank X60 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 ff -,- <br /> DOMESTIC/PUBLIC <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 10 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal J71 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout X41A Ceine / — _ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �d/.2q l <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 _ 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 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 Inspection prior to grouting and a final inspection. <br /> Signed X , .C��`,�6/-�' �. . . Title: A Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Ph se 11 Grout-Inlsctlon III Final Inspection <br /> Inspection By1 0—'0D'ate� _114-yK Inspection By Date <br /> f- I /Ot _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNhT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ` �� s• tyjQ <br /> LESS <br /> PRORATION <br /> - PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �nLl <br /> Received by - - Date Receipt No. Permit No. Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.eox 2009 STOCKTON,CA 95201 _ <br />