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ApplicationsWill BeProcessedWhenSubmitted Properly Com t d e�VrLYo4igd Tg6A�lion. 1 <br /> FOR OFFICE U,SE. APPLICATION ' <br /> ` (For Non-Transferable, Revocable,anda <br /> �@ 1 1980 <br /> �j PUMP&WELL �. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN j044 ,!U(N i_nCAL i <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct anW&AfsttTHh&&lTFi' Gih described.This application is <br /> made in compliance with San Joaquin C unty Ordina a No. 1862 and the rules and regulations of the San Joaquin Loc I Health District. <br /> Exact Site Address , } City/Town �lc�r/ <br /> Owner's Name V S e Phone S-7 !gSfrJr <br /> Address City 1 <br /> Contractor's Name ICJ nL S r License# 3�S AM— Business PhoneKSS 3 <br /> Contractor's Address Als-0, � Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on F'e With SJLHD? Yes—XI No t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRL� <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> -Sewage Disposal Field — Cesspool/Seepage Pit Other Ty <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 7 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> KDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION IT ROTARY Type of Grout <br /> ❑ DISPOSAL - ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ,,/ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �(o O-S 7`/� <br /> Type of Pump b 11 C H.P. �� <br /> PUMP REPLACEMENT: ® State Work Done - ! + <br /> PUMP REPAIR: ❑ State Work Done M <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> - s <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 /> Homeowner 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." <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 call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title- _ . _ - Date: k <br /> (Draw Plot Plan on Rever�Side) j <br /> F R D ARTMEN USE ONLY <br /> 06 <br /> PHASEI - <br /> Application Accepted By �p Date A2,9/k.r�D ► <br /> Additional Comments: <br /> P ase I rout Inspection se III Final Inspection <br /> Inspection By Date Inspection By Date <br /> .fee Is Due: ❑ ANNUALLY ❑ PER UNIT 'VPPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 2 <br /> J i <br /> �lal3 h <br /> Received by Date Receipt No. Permit No Issulince D to Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES $Q1 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 } <br /> #. �_ � 1 <br />