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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> c6e (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br />`< ENVIRONMENTAL--HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ,WATER QUALITY <br /> Application is hereby made tothe 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 uin C unty Or m ce No. 1862 and the rules and regulations of the San J I Local Health District. <br /> F Exact Site Address �' Y�. �.�-. _ City/Townes <br /> i <br /> Owner's Name -44,. f k.)&:"! d_e_a_"° Phone <br /> Address �a / --A1e 0 041P- _T City- <br /> I Contractor's Name r .�1 ALicense#&9 Business Phone 2 .144),-74 '74 <br /> r Contractor's Address r <br /> ' Emergency.Phone.. -_� -.; ,— '- x <br /> I Is.Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORT( (CHECK): - NEW WELL❑-. DEEPEN ❑" RECONDITION❑''" '-DESTRUCTION❑ <br /> 1 WELL CHLORINATION ❑ WELL,ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONX PUMP REPAIR❑ <br /> REPLACEMENT❑ ► - <br /> DISTANCE TO NEAREST: Septic Tank - Y 1- Sewer Lines Pit Privy <br /> Sewage Disposal Field •+�4 _'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 ❑'OTHEROther Information <br /> ❑ GEOPHYSICAL Surface SealInstalled By: <br /> PUMP INSTALLATION: Contractor K <br /> Type of Pump p H.P. <br /> t PUMP REPLACEMENT: State Work Done . u_*4e*eA, i&= / ,4 <br /> PUMP REPAIR: ❑ State Work Done ` <br /> I DESTRUCTION OF WELL; Well Diameter Approximate Depth 49 <br /> s <br /> .,.Describe Material,and Procedure. p,Y -y <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 orsub-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 /> 9 <br /> ' I ill call for a Grout Ins lo priMouling an final inspection. ..-� r. _ ,•.',. - <br /> Signed Itle' Date O Z <br /> {Draw Plot Plan on Reverse Side} # <br /> FOR DEPARTMENT USE ONLY ; <br /> PHASE I <br /> Application Accepted B Date <br /> Additional Comment ` <br /> Phase II Grout Inspection ase III ZWon <br /> Inspection By Date Inspection B <br /> Fee Is-Due: 1:1 ANNUALLY ❑ PER'UNIT ❑ PER SITE ❑ EACH ❑ Jan 1 &Received By Januar 31 El July 1 &Received By 3uiy 31 <br /> REMIT <br /> BASE - EXPLANATION BILLING_ REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED _ C AMOUNT <br /> FEE <br /> '-LESS <br /> PRORATION <br /> ---PLUS - <br /> PENALTY <br /> OTHER .f.._— <br /> OTHER <br /> -Received by Date - Receipt No. _ Permit No. - Issuanc 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 />