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s" Applications Will Be Processed When Submitted ProperlyCompleted. BeSureToSignTheApplication. <br /> -FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> F PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Appl ication is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San JJpaquin County Ordiinpnce No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /�Y 9� za/"I��e, ' r/q _ City/Town <br /> Owner's Name d �C' 'sU Phone 94V`z Z F <br /> Address /0 yCity SIte G e0 <br /> Contractor's Name PC raicrI 7 License#�� 9166 Business Phone�9/� �7/-�'234 <br /> Contractor's Address of Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes .)( _ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT.d 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 <br /> INTENDED USE TYPE OF WELL <br /> I] INDUSTRIAL El CABLE TOOL Dia. of Well Excavation ;IG i <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC .0 DRIVEN Gauge of Casing �) <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: f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done E <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 3 /!?G / Approximate Depth <br /> Describe Material and Procedure i r <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. .rI <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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> IIII II fo Groutiinns`pection or to grouting and a final inspection. [ <br /> Signed X 7th --G� Title: --�✓rGr,�/41! �il Date f� '7 <br /> (Draw Plot Plan on Reverse Side) VBG <br /> FO DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By <br /> °"� Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phasfl Final spection <br /> t I <br /> Inspection By 9 Date llnsp�lc�tlon � fA Datk w <br /> Fee IS Due: ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ A H Janua. 1 & :Li .By Ja u 1 my 1 &Received By July'31 i <br /> BILLING R T ANCE $ REMIT <br /> SASE EXPLANATION rA OUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> t <br /> FEE L °t <br /> I <br /> LESS <br /> PRORATION <br /> 1 PLUS <br /> PENALTY . <br /> OTHER <br /> OTHER <br /> C� <br /> ­7_c-1ZG Z <br /> i Received by Date Receipt No Permit No. issuance Date Mailed Delivered <br /> 4-4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 <br /> r <br />