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Applications Will Be ProcessedWhen SubmittedProperly Completed. BeSureTo sign TneApplication <br /> J,FOR C FFICE USE: APPLICATION <br /> (for Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) V Tf,QpILITY <br /> Application ishereb madetotheSanJoaquin Lo al l n oA I c s ctand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Or c aPT6pYPe f�s egulations of the San oaquin Local Health District. <br /> Cit /Town <br /> Exact Site Address p f Y . /1 <br /> Owner's Name , aL, ;2/11 ✓ 4-121161.) DEC 18 1980 Phone <br /> Address ' g �, City <br /> Contractor's Name ,t1 SAN -i0AQ''Jt1 rs 323 Business Phone 4 x <br /> 6G l� S <br /> Contractor's Address _�G /jnF /7� HEALTH DI <br /> �6P <br /> Phone ► <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No © y <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECOND ION❑ DESTRUCTION 11 !� '7 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ElOTHER PUMP INSTALLATION ❑ PUMP REPAIR❑ ' <br /> REPLACEMENT❑ ! - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other _ b <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ yNDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 13 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑�8tate Work Done <br /> PUMP REPAIR: estate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth v ii <br /> Describe Material and Procedure <br /> — 41 <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. f; <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 will call for aI?Grout Inspection prior to grouting and a final inspection. <br /> Signed X�r,P c,.L "w- Gla �- l` ) Title: Date: 1�'- 7- 0 i <br /> (Draw Plot Plan on Reverse Side <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By —""� y 1 Date�L � <br /> Additional Comments: <br /> Phase II Grout Inspection a III inal Inspection 7 <br /> Inspection By Date Inspection By Date <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 EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> � - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 3 <br /> r;)— <br /> Received by Date Receipt No. Permit No Iss nce Datia Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />