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LLUJ <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The A�t1ationFEB c3 2 1983 <br /> FOR OFFICE USE: APPLICATION �i ( 63 <br /> (For Non-Transferable, Revocable, Suspendable) PUMP b;TU`N LOCALL <br /> ENVIRONMENTAL HEALTH PERMIT HEAUM 61STR1CT, <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 Count Ordinance No. 1862 an th rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address ®� 1aL >�/11/ } A� City/Town <br /> JG�el ea J <br /> Owner's Name D A W. E A f� !Y Phone ?80P"_�o lu <br /> Address - <br /> SCA1o1 • <br /> m } �� � � City" � <br /> Contractor's Name 7 d111 .90 A), License#,0`29410 Business Phone <br /> Contractor's Address 410 Emergency Phone <br /> �� t� /�► <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD?- YesNo <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ _ DESTRUCTIONWELL ❑ - <br /> REPLACEMENT❑ (V✓ �Tt6i. 0 WELL 0 B W i-a O❑ f�OTHER M_M PO� INST,4LLA0T SZ'w#cP1.111iIP bV J3EPAI Me, <br /> DISTANCE TO NEAREST: Septic Tank -Sewer Lines Pit Privy <br /> CU�7 <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 /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal � . <br /> © CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information''' <br /> ❑ GEOPHYSICAL urfac Seal Installed By:. <br /> PUMP INSTALLATION: Contractor- OF <br /> n t [JN <br /> Type of Pump = ._— t H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approxirrlate,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 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 II o a rou spection prior to grouting and a final inspection. <br /> 1 <br /> Signed X Title: L�� Date: .� � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTM NT U ONLY <br /> PHASEI y <br /> Application Accepted By Date k3 <br /> Additional Comments: <br /> PhIK [ rout InspectionIII Final Inspection <br /> P s <br /> Inspection By Date Inspection By I t Date <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Janu 1 ❑ July 1 &Received By July 31 <br /> ' REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ( DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS — <br /> PRORATION <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> i <br /> OTHER <br /> Received by Pate I -Receipt No. Permit No. •ksuancd Date Mailed- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1901 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />