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Appflcation II rocessed W ubmitted Properly Completed. Be Sure To Sign The Application. <br /> .Fr/ BICE USE: ` �� trf 1980 APPLICATION <br /> f (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> R HEALT QDIN LOtRUIRONMENTAL HEALTH PERMIT <br /> STRfCT WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 6258 S. Santa Anna Rd. _- City/Town Stockton <br /> 3Zharles Norwood 463-1589 <br /> Owner's Name Phone <br /> Address 6258 S. . City, , <br /> ac a a, Inca �, s 3 o p <br /> Contractor's Name License# B s ss P n <br /> Contractor's Address 417 ' Jackone . Emergency Phone �'• <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ V1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT E <br /> DISTANCE TO NEAREST: Septic Tank?5 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 <br /> 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 pp1"�� <br /> 11 GEOPHYSICAL Surface Seal Installed By: (4 <br /> PUMP INSTALLATION: Contractor <br /> T pe of Pump Sub H.P, 2 <br /> a <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ' <br /> i <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 become subject to workman's compensation laws of California." w <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 /> I will c r a Grout In e i prior to grousing and a final inspection. <br /> Signed X Title: Sect-Treas. Date: ' <br /> (Draw'Plot Plan on Reverse Side) <br /> FO DEPA TMENT U ONLY <br /> i PHASE ` <br />{ Application Accepted ByDate<� <br /> Additional Comments: <br /> Phase II Grout Inspection f Phas l nal Inspection <br /> Inspection By Date Inspection By Date <br /> i <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT �/PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 j <br /> REMIT I <br /> BILLING REMITTANCE $ ' <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED i <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> t. PLUS <br /> PENALTY <br />' OTHER # <br /> OTHER <br /> Cj73oy 7-31-�0 _ � <br /> Received by Date Receipt No, Permit No. Issuance Dale Mailed Delivered a <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 ``I <br />