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- ApplicationsWillBeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE., APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WI=LL <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 oaq 'n County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local He lth District. <br /> Exact Site Address City/Town <br /> Owner's Name n 14^+ 4kilip-Di0 U Phone <br /> Address , City K a <br /> Contractor's Name 0,LISA!( WRt t FQUIArft.License# 4Gaz Business Phone�_6J �_�- 7 <br /> Contractor's Address z.Oz� E, C� ��L1!k-i Emergency Phone Tri Z'6 Z3(w <br /> Is Certificate of Workman's Compensation I,nsu3 �n File With SJLHD? Yes L� No <br /> TYPE OF WORK (CHECK): NEW WELL u DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT❑ { <br /> DISTANCE TO NEAREST: Septic Tank �� Sewer Lines l QQ Pit Privy <br /> Sewage Disposal Field Cesspool/Sgepage Pity Other <br /> Property Line /d Private Domestic Well /46 Public Domestic Well �� <br /> INTENDED USE TYPE OF WELL r <br /> qN <br /> ❑ IRIAL ❑ CABLE.TOOL Dia. of Well Excavation <br /> , <br /> �DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑>nT <br /> VEN Gauge of Casing <br /> ❑ IRRIGATION ❑ L PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION OARY Type of Grout <br /> 0_I]ISPOSAL _.._ � _ '� OTHER Other Information <br /> © GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. ..� <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 Count <br /> ordinances, state laws,,and rules and regu12tions 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 win1lfora Gr Inspection prior to grouting and a final inspection.' C <br /> Signed X T Title: —� _ Date: 14 Sgt"ghjw�9 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Dateq- 0- <br /> Additional Comments: _ <br /> Phase II Grout Inspection a P a e III F' al Inspections <br /> Inspection By l✓ Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY-0 PER UNIT—-'❑-PER SITE �{].EACH ❑ January l &Received By January 31 ❑ July 1 &Received By JWy 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> z AMOUNT <br /> FEE �da <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �. ._ .. <br /> 1eZl <br /> fl/1 7t-79 <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.Boy 21309 STOCKTON,CA 95201 <br />