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Applications WIII Be Processed When Submittec,40_C'operiy Completed. Be Sure To Sign The Application. <br /> A F(iR OFFICE USE: APPATION .� <br /> (For Non-Transfer le, lurcable, Suspendable) ,4 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto constructand/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinanc 1862 and the rules and regulations of the San Joaquin L Cal Health District. 6 <br /> Exact Site Address �U hit City/Tow/n� ,rS6AIL 7,Ar <br /> Owner's Namey`EA,4_ al i/si 4"a,,, _ Phone <br /> Address ,1 4I Z Ar W'd V city��i?�E'svtc>nt� <br /> Contractor's Name License#222-1-64 Business Phone <br /> Contractor's Address ..�Z,? &L 1Z. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_�< No <br /> TYPE OF WORK (CHECK): NEW WELL A, DEEPEN El RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 04 <br /> REPLACEMENT❑ ! SP f4 J <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 4- Pit Privy T® 00 <br /> Sewage Disposal Field rQL) /It Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well .5-0 14 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 l�ti <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing G 4.s!� i <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: Gr Contractor <br /> I' Type of Pump H.P. <br /> PUMP REPLACEMEN : ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Vill <br /> Describe Material and Procedure <br /> 1 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wil :&Ilfor a Ceout spec n prior to grouting and a final inspection. Jas <br /> Signed X Title: Aetic Date: ! 'L 1 �� <br /> (Draw Plot Plan on Reverse de) <br /> FOR PEPARTMENT USE ONLY <br /> PHASE I /j_ 7q <br /> Application Accepted By """"` Date �l/l/' / <br /> s <br /> Additional Comments: <br /> ��1 Phase II Grout Inspection � P III Final s ection <br /> Inspection B Date Inspection B Dat f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By J ly 3 <br /> REMIT ILA <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 04 AN-3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 5<sko p <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C 5 1 <br />