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mppiwauons <br /> IBe ProcessedWhenSubmitted Properly Completed. Be Sure To Sign�The Application. j <br /> FtaR OFFICE use: APPLICATION <br /> (For Non-Transterable, Revocable, Suspehdabie) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> PUMP&WELL <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 wi h S. ioaq�uin ounty r finance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> ~ City/Town x <br /> Owner's Name 'S TAT l d I` Cit_. t�$a,– �R Phone <br /> Ad d ress City <br /> Contractor's Name E --r kA n7 D r` _fl_I(�ICense -fnt–'Z Business Phone 6.J-9<) <br /> Contractor's Address A-S r "bxvK Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? <br /> Yes_K— No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <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 r, <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation T <br /> © DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 19 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 112.0" <br /> - Approximate Depth <br /> Describe Material and Procedure e- L,4}_�"p S O� LCpN C2� &R43IlA TD <br /> R* f <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:'Y certify that in the performance of the work fpr which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I 11 call for a Grout Inspection prior to grouting and a final inspaebon. <br /> Signed X Title: 1 Date: / C, <br /> (Draw Plot Plan on Reverse Side) <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I \� 1 <br /> Application Accepted By `�►'� cbllDate <br /> Additional Comments: <br /> Phase Il Grout Inspection Pha a III Final �In�s�pe�on <br /> Inspection By eA Date Inspection By D`ate G� <br /> Fee IS DUe:.❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar 1 &Received B Januar 31 <br /> -__ y Y Y ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING -REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE it—D <br /> LESS <br /> PRORATION {{ <br /> PLUS f <br /> PENALTY <br /> OTHER <br /> s <br /> OTHER <br /> �ro 97o 6S <br /> Received by bate Receipt No. Permit No. - Issuance Date Maifed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Box 2009 STOCKTON,CA 95201 <br />