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Applications Will Be Processed When Submitted Properly_Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: a APPLICATION Neu) Cj0n s .-,u 07/70 <br /> (For Non-Transferable, Revocable, Suspendable) ri <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT 4 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY. <br /> Application is hereby madeto theiSan Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with�/San Joa uin County Ordinance,No. 1862 and the rules and regulations of the Sa Joaquin Local Health District. <br /> Exact Site Addresszp y� ��GG1^I !• - " x. City/Town � d <br /> Owner's Name r�/JI. 4[7 -Phone ��-A-0 t. <br /> Address yyam�'` �/ �A" �` ' City 6 / - <br /> Contractor's Name /S/�C74(ko v�rc-�i G✓e%,1�r;�f�` S License# Business Phone <br /> Contractor's Address &mergency Phone / f 1-Y <br /> Is Certificate of Workman's Compensation Insurance on File With SJ HQ? „Yes No <br /> TYPE OF WORK (CHECK): NEW WELI� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> t WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 'PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> II - - <br /> DISTANCE TO NEAREST: Septic Tank Ay Sewer Llnes Pit-Privy -/ <br /> Sewage Disposal Field Cesspoo/Seepage Pit O her�Q <br /> } Property Lin Private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE OF WELL <br /> f ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation f� <br /> DOMESTIC/PRIVATE 13 DRILLED "Dia. of`Well Casing _ <br /> I. <br /> 13--DOMESTIC/PUBLIC P ❑ DRIVEN Gauge of Casing AR 414a—' <br /> ❑ fRRIGATION ❑ GRAVEL-PACK—� _Depth:of Grou Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout e e_l'r,eAJ <br /> F ❑ DISPOSAL I ❑ OTHEROther Information <br /> ❑ GEOPHYSICAL `' - S rface Seal Installed By:.M-,r e r <br /> i <br /> PUMP INSTALLATION: Contractor �O 1 Au <br /> TYPe:of_Pump H.P. �A�� r� <br /> PUMP REPLACEMENT: ❑ -State,Work bone- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ', Well Diameter- " Approximate Depth <br /> u Describe-Material and'Prbcadure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> g 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 workforwhich 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 /> t permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w' call for a Grout pection prior to grouting and a final inspection. = <br /> Signed X Title: Date: <br /> r (Draw Plot Plan on Reverse Side) <br /> _ II <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASEy <br /> Application Accepted By' <br /> Additional Comments: _ <br /> } Ph se II Grout Innssp, ption — y , h III Final Inspectlo <br /> Inspection BF Date -2 d-O Z Inspection By r Dat <br /> 'Fee IS Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE� ❑ EACH❑iJanuary 1 &Received By January 31 ❑ July 1 &Received 9y July 31 <br /> REMIT <br /> " BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> � AMOUNT <br /> EEE <br /> LESS Y. <br /> PRORATION <br /> PLUS <br /> PENALTY `� `•F" <br /> OTHER <br /> OTHER <br /> Received Ey D to Receipt No. _ Permit No. ,,. ;Issue ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES a 1601 E.HAZELTON AVE.,A.O.Boa-2009 STOCKTON,CA 95201 =o__ <br />