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r Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Site Application. <br /> FOR OFFICE USE: APPLICATION JUL 3 -1 1981 <br /> r (For Non-Transferable, Revocable,Su spendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN LOCAL <br /> WATER 4untlTr ' <br /> HEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) �.. t ..� = <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct an 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 141Q h I- f City/Town . . IV ALe n. <br /> Owner's Name /A C16 C RO Phone' b"y 441-�9- <br /> Address city <br /> Contractor's Name rix? �S.� a-� -- 's •+�' License# 79040 Business Phone <br /> Contractor's Address r2o&3t Emergency Phone S' m <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No -� <br /> I TYPE OF WORK (CHECK): NEW WELL❑ ' DEEPEN ❑ RECONDITION 11' "DESTRUCTION[]'— 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT t@ Q�J <br /> DISTANCE TO NEAREST: Septic Tanks Sewer Lines Pit Privy J <br /> r 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 /> i ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing, <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -� <br /> r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> j ❑ GEOPHYSICAL Surface Seal Installed By, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: IN State Work Done 9La_. .1 f <br /> PUMP REPAIR: ❑ State Work Done <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 /> Homeowner or licensed agent's signature certifies the following:1 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will pMl for Grout Inspection prior to grouting and a final Inspection. /� f <br /> Signed , ° 1 •rJ Title: Date: rY' / <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> K., Additional Comments: <br /> Ptwse 11 Grout Inspection w se II Final Inspectio W✓�I <br /> Inspection By Date Inspection Date <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i: REMIT <br /> RASE EXPLANATION BILLING" REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S `� <br /> LESS <br /> PRORATION ; <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by ate 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 2009 STOCKTON,CA 25201 <br />