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.IM ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be SureToSign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> j� (For Nan-Transferable,'Revocable,Suspendable) <br /> jM ENVIRONMENTAL HEALTH PERMIT PUMP WE <br /> i <br /> WATER UALITY <br /> (COMPLETE,:IN TRIPLICATE), Q '``' I'r7S( —(1{tq� J <br /> Application is hereby madetotheBanJoaq'bin Local Health District for a permit to construct and/or installth?work,herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sart Joaquin Local Health District. <br /> Exact Site Address <br /> aF �'D /� /� 7iTYI�I.City/Town V/eTa1E' <br /> II --- <br /> Owner's Name /�Ji4 Phone: X974 <br /> Address ��rv27 VA*5 f/LS//A/€ 77�V� — City 40Df 175~_ <br /> ` 33-77 <br /> Contractor's Name /I l/ 1�/�LL T�i�lLld�iG License#3379W.Z. Business Phone a <br /> Contractor's f ddress Paal3 G'! /i�,eiVT�,95Z Emergency Phone -�4f�S <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF W6RK (CHECK): NEW WELL DEEPEN ❑ RECONDITION u -DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ ' <br /> DISTANCE TQ NEAREST: Septic Tank 2a2a�Z Sewer Lines Pit Privy <br /> Sewage Disposal Field n2Cesspool/seepage Pit Other <br /> Property Line_ -f1 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ` <br /> ❑ INDUSTRIAL 71 CABLETOOL .Dia.-of Well-Excavation <br /> DOMESTIC/PRIVATE <br /> y <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ,p <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAfL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: / O� i � �✓� { "x� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACE=MENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State.W.ork 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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." �� I <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 call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X 1: Title: Date: <br /> J� (Draw Plot Plan on Reverse Side) <br /> Ip FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date i <br /> ;II - <br /> Additional Comments: i <br /> mt= <br /> Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By - at�' ` <br /> I. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE)%­-?�Zj ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 i <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS IM: <br /> PENALTY <br /> OTHER�j <br /> !!l111 ti <br /> OTHER 4 <br /> Receives by Date Receipt No Permit No. lsduanc6 Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P-O.Box 2009 STOCKTON,CA 95201 <br />