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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. / <br /> '-'rf�ii�OFFICE USE: APPLICATION � <br /> (For Non-Translerable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) Jgp0 W t-T1liv-,�-WATER QUALITY J; <br /> 10 r3--0a 2z <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install theworkherein described.This applicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the lrules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_ V.-�'.:s;Ad L'i'5 .tete RW City/Town ' 0, <br /> Owner's Name ` � !l t7 j tF Phone .s. <br /> Address City s1'6eA-7-z* 11 <br /> Contractor's Name I' � ` L+ t License# ':Z Business P one <br /> j <br /> Contractor's Address + ><' Emergency Phone Z <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTI N❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION PUMP REPAIR© <br /> REPLACEMENT❑ e <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Fie 11 Cesspool/Seepage Pit Other <br /> Property Linee7Private 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 Casings" <br /> ❑ IRRIGATION _ ❑ GRAVE=L PACK'_. _ Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION L ROTARY - Ty`pe of Grout x°- dLs .• <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> El GEOPHYSICAL Surface Sea Installed By: .. �,� "etr >f"w liar <br /> PUMP INSTALLATION: Contractor �1a-" �� <br /> O <br /> Type of Pump wC+ t+ H,P, <br /> PUMP REPLACEMENT: ❑ State Work Done _71,0th-14 ")U44 <br /> PUMP REPAIR: ❑ State Work Done i <br /> DESTRUCTION OF WELL: Well Diameters --- - - Approximate Depths �(�s <br /> Describe Material and Procedure_- �r <br /> ' I hereby certify that I have prepared this application-and that the work will be done in accordance with San Joaquin County <br /> iordinances, 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 forwhich this permit <br /> is issued, I shall not employ any person iri 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 p for to grouting and a final•inspecti6n. # <br /> Signed Xw Title: Date: )4X <br /> w (Draw Plot Plan on Rever'§e Side) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By '"` Date <br /> Additional Comments: -* <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> Inspection By Date Inspection By Date <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> BILLING REMIT ANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE PATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 <br /> 9-1 �- 6 ? <br /> Received by Dat Receipt No. Permit No. Issuance Date, Mailed Delivered <br /> APPLICANT—RETUR ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />