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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application_ " <br /> FOR a FICE USE: APPLICATION <br /> <0 Pipe (For Non-Transferable, Revocable,Suspendable) ' <br /> ENVIRONMENTALPUMP&WELL <br /> HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora 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 regulations of the San Joaquin Local Health District. <br /> Exact Site Address 17 C�rL � ? City/Town AW49e2 _ <br /> I Owner's Name _/C/�f � �L /C�.AE/U�...___ Phone <br /> Address L-1iE' City <br /> Contractor's Name cense# Business Phone — <br /> Contractor's Address Emergency Phone I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION.9' PUMP REPAIR El <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 12F WELL <br /> r ❑ INDUSTRIAL ABLE TOr� Dia, of Well Excavation Ids' <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing / <br />(` ❑ DOMESTIC/PUBLIC - ❑ DRIVEN Gauge of Casing <br /> IRRIGATIO ❑ GRAVEL PACK Depth of Grout Seal <br /> r CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �y4 <br /> t PUMP INSTALLATION: Contractor JAZZ,—, <br /> Type of Pump 4114F r,— H.P. 45" <br /> ) . <br /> PUMP REPLACEMENT: ❑ State Work Done GG/EGC_ Ti�S'�C_G L <br />!. PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br />' D scribe Material and Procedure ! I 1 ALr �,g <br /> .-I hereby certify that I have prepa ed this applicat" nand 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> f - 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 i sued, I shall emp, y persons subject to workman's compensation laws of California." <br /> I�tlawt r Grt I pction prior to grouting and a final insp ion.Signed X � Title: � Date: Gni <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By + Date )V 2 31 <br /> Additional Comments: kita 1AA011p <br /> Phase 11 Gr ut Inspection ase III in "nspeclio <br /> n1 <br /> Inspection By Date Inspection By <br /> Fee Is Due: 11 ANNUALLY El UN"7 =_1ER SITECH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: 11 ANNUALLY El PER U N <br /> REMIT <br /> BASE EXPLANAT30N BILLING REMITTANCE $ I <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE w A u <br /> LESS 4 <br /> PRORATION <br /> r <br /> PLUS -' <br /> PENALTY J <br /> OTHER <br /> OTHER <br /> I <br /> D D <br /> Received by I I Date.k Receipt No. Permit No. Issuance Dae -Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.'HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />