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Applications Will Be Processed When SubmittedPropertyC:ompiewa. oe oure IV�U,yr. •��+rr <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is herebymadetotheSanJoa'quinLocalHealthDistrictforapermittoconskructand!orinstallthework herein described.This application is <br /> made in compliance with San,-Joaquin County Ordinance No.,,1132 and t rules and regulations of the San Joa pin Local HealthDfisU4ct. <br /> Exact Site AddressCity/Town il � <br /> / i <br /> owner's ame 4lk F� U } C Phone �� Z-r <br /> City �• <br /> Address •fl W^x, 7•- j <br /> Contractor's Name b (! V,! ense#4a;V:�- Business P�hone <br /> Contractor's Address Emergency Phone;wC 4 <br /> Is Certificate of Workman's Compensation nsurance on File With SJLHD? Yes X, No� t <br /> TYPE OF WORK (CHECK): NEW WELIll DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ W. t <br /> DISTANCE TO NEAREST:k Septic Tank A)- 81�S�ei�pryerrLcines �J Pit Privy � Other <br /> Sewage Disposal Fi+Id 1 I_V LJ�_ Cesspool/Se�page Pit A <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> A\ AJ4 <br /> ❑ INDUSTRIAL CABLE TOOL Dia. ofiWell Excavation <br /> 11DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing ) <br /> XDOMESTIC/PUBLIC <br /> 13DRIVEN Gauge of Casing - �, <br /> ❑ IRRIGATION El GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTIONDxROTARY Type of Grout <br />` ❑ DISPOSAL ❑ OTHER•. Other Information ij ! <br /> 1111411 , <br /> ❑ GEOPHYSICAL y <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: � '7Contractor <br /> Type of-P_ump H'P <br /> PUMP REPLACEMENT: State Wok Done <br /> PUMP REPAIR: ❑State Work Donut- _ � <br /> Approximate Depth o <br /> DESTRUCTION OF WELL: We11 Diameter <br /> } Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done'in?aecortlance with San Joaquin County <br /> ordinances, state laws, and rulesr nd regulations of tlae,5an Joaquin Local Health District:, <br /> Homeowner or licensed agent'stsignature certifies�the foll�wmgR``I certify that-inkhe performance of the work toy which this permit <br /> is issued, I shall not employ all person in such mann Iasjto become subject to workman's compensation laws of'California." <br /> to "I certify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifies the <br /> permit is issued shall employ persons ns subject to workman's compensation laws of California." <br /> i I I all for rout Ins�p'ection prior to grouting and a sinal inspection. <br /> Signed X <br /> Title: �7t-�y`� Date <br /> (Draw P.lot Plan on Reverse Side) <br /> 6F0R DEPARTMENT USE ONLY �� <br /> PHASE 1 Date 704-0 <br /> C Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ duly 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> IF PLUS <br /> PENALTY <br /> i OTHER <br /> OTHER <br /> aims 3 T <br /> ID e Receipt No Permit No. Issuance Date Delivered <br /> Mai4ed <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.D.Box 2009 STOCKTON,CA 95201. .. <br />