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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY `? 07 S- veo- Z_. ? <br /> Application is hereby made to the San Joaquin Local Health District 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 rules and reegUllaati np t e San Joaquin Local Health District. <br /> Exact Site Address 2:1)toy SO Ro 'Of 1AP PAM0MAIOCIty/Town -Si�t >�Kt"�'�-� <br /> Owner's Name 4ro ca' Phone ZSf <br /> Address N City ' <br /> Contractor's Name 'f�4-S ooypf ' icense• 9 05, Business Phone �.2 opt� �` � —moo 2.7 <br /> Contractor's Address OAfL LiF v OF gE�mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JL D? Yes Pe No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIOO�NGD <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION. PUMP REPAIR❑ j <br /> REPLACEMENT❑ ////// <br /> DISTANCE TO NEAREST: Septic Tank 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 <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 Si .�+ <br /> Type of Pump C6uti324 YCC> FLA.A.I�A%9 14 H.P. <br /> PUMP REPLACEMENT: XState Work Done 1 klSTla LL- �'.s+`a•t.�Z'r�f fd��.vi.1 � > PIAL, _ <br /> PUMP REPAIR: ❑ State Work Done -�IAtSzyd►�L 4y` �'- Gns.LJ2.iF@.E�' "��r <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:'Y 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 will call for a Grout Inspection prior to grouting and a final Inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection phase III FFinal Inspection <br /> Inspection By Date Inspection By G ( Date //' Z � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 \ <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLRNATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE J Lq,� <br /> —y 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> l <br /> Received by Date Receipt No. Permit No kissuance Mte Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Sam 2009 STOCKTON,CA 95201 <br />