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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> FOR OFFICE USE: APPLICATION I <br /> (For Non-TtansferaVi, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 �quiq�oou5ty©LIJ�nance No. 1862 and the rules and regulations of the San�1,pBaA'VeLCogal Health District. <br /> Exact Site Address fn�gt] Y C V G City/Town 1�1 t <br /> Owner's Name Mike 'G i Ica s Phone �2 — — <br /> :s <br /> Address . City['g+�P c t:O r <br /> Contractor's Name _jinni n ga 'BrosLicense# I Business Phone 545-1-185 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X— No <br /> TYPE OF WORK (CHECK): NEW WELL R DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> f <br /> DISTANCE TO NEAREST: Septic Tank 1004- 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 OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 12 <br /> 0 DOMESTIC/PRIVATE 70 DRILLED Dia. of Well Casing si <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION EXGRAVEL PACK Depth of Grout Seal 50 <br /> ❑ CATHODIC PROTECTION 7b ROTARY Type of Grout Bentonitp <br /> ❑ DISPOSAL ❑ OTHER Other Information---slab ti,T pS,rne ' <br /> ❑ GEOPHYSICAL Surface Seal Installed By: T)r! i l er <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. rn <br /> V ' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work jDone <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 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 /> is issued, I shall not employ any person in such manner as to became 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 /> will call for a Grout Inspection prior to grouting and a final inspection. <br /> Title: v 1 Date: 2- <br /> Signed <br /> (Draw Plot-Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By l Date <br /> Additional Comments: f/ $ <br /> Phase II Grout Inspection Prse III Final inspection <br /> Inspection By Lq_ Date 9 Inspection By�__ Date <br /> Fee IS Due: 11ANNUALLsY El PER UNIT El PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JuEy 31 <br /> REMIT <br /> BILLING REMITTANCE $ i <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � <br /> LESS j <br /> PRORATION a <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I� OTHER <br /> �3 <br />' yrs G <br /> kReceived by 11 ate Receipt No. Permit No. l4suance Date Mailed Delivered <br /> �'�.� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95:2�a_ <br />