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AJl t�m!4,V l)e&ok6ssM 11ansferable, <br /> ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR.PFFI,�USE: APPLICATION <br /> 0 C T 21199 or Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> J :tL UIN LOCAL WATER UALITY <br /> (COMPLETE IN TRIPLICA �� r��[I..i.tiI��� 1� ��+ 4 <br /> Applicationisherebymadeto LJcW.Illi!•'1&Ez�r�g.TIthDistrictforapermittoconstructand/orinstaIIthe workhere indescribed.Thisapplicationis <br /> made in compliance with San Joaquin Count Ordinance No. 18 and the rules and regulations of the San Joaquin Local Heal thhRistrict. <br /> Exact Site Address S c— 6_d,ZJ, �� G�� City/Town �I P/P La (_c2-✓�9l2 <br /> Owner's Name �l �e +a A c? _ Phone <br /> Addresst e a(uJE1a crf. _ -11_� City P t?(- A <br /> Contractor's Name �'�` !7 ��c�C. �+ �, License# n2 Business Phone �G <br /> Contractor's Address !/L- 'T-- /2Icp.` n - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ CA <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION P�-' PUMP REPAIR C1 <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 OF WELL <br /> 1,,,,1. �INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation I <br /> I 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 S face Seal Installed By: <br /> PUMP INSTALLATION: Contractor f!� r/ ` <br /> Type of Pump s H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done Zile- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r' Approximate Depth <br /> Describe Material and Procedure <br /> l + <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 thework 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 signalure 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 r a rout Inspection prior to groutin anny a final inspection. <br /> Signed X _ ��. �r <'� �'fitle: Date: /0 —/,bee "40 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I j A. _ <br /> Application Accepted By ""`�-�--� Date � — <br /> Additional Comments: __j�y <br /> Phase 11 Grout Inspection Phase III Final Inspection <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 /> _ AMOUN7 <br /> FEE S 0 5 00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> pit <br /> IY1 <br /> Received by bate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> ;;. -APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E,HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br />