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Applications Will Be Processed When submitted Properly Completed. Be Sure To Sign The Application. I " <br /> FOR OFFICE USE: APPLICATION ' �o <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&;'V>:LL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) � _ J�¢UALITY <br /> Application is hereby made to the Sa,29'quin local He h D' rict for a 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 rut s and re ula ions of the S n Joaqui Local Health District. <br /> Exact Site Address Ki dews C1 Ub at N/W corner of HW Y �20 & I c IW/�4vvn1 Ian eca <br /> Owner's Name George Perry Phone <br /> Address Box 28 Steward Rd city Manteca <br /> Contractor's Name Q►rN 9RQl�I^„--P'v,M. License#191 n 12 Business Phone 369 71 <br /> Contractor's Address860 G RINE CT 1 DJ rn Emergency Phone <br /> vvv _p <br /> �— t <br /> AME <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No r 111 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN E] RECONDITION❑ DESTRUCTION❑ u” t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PX PUMP REPAIR❑ <br /> REPLACEMENT❑ —G l <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �r <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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor SAN JOAQUINPUMP CO H P 1/2 HP Type of Pump <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit d <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 call for a Grout Inspection p ' r to grouting and a final inspection. <br /> Signed I T Y R Title: OFFICE MGR Date: ��1�� <br /> (Draw Plot Plan on Reverse Side) <br /> PHASEI /� F R DEPARTMENT USE ONLY <br /> d <br /> Application Accepted ByDate <br /> Additional Comments: <br /> se I rout inspectiow he e III Final Inspection <br /> Inspection By Date Inspection By �� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE "s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 7-1 <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.Box 2009 STOCKTON,CA 95201 <br />