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FOR OFFICE USE: APPLICATIUN <br /> (For Non-Transferable, Revocable, Suspendable) l <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 with San Joaquin�]County Ordinance No. 1862 and the rules and regulations of the San Joaquin Lo I Health District. <br /> Exact Site Address ?clY/SC' 9nr�3 City/Town <br /> Owner's Name O1' Phone �]?•SL it '..L <br /> Address City 64" Lf b OCI <br /> Contractor's Name License N Z,Bussiiinnessss.P,hone <br /> Contractor's Address ' Emergency Phone Its ,J3_� f�'J� <br /> Is Certificate of Workman's Compensatio Ins rance on File With SJLHO? Yes _ No _ __ <br /> TYPE OF WORK (CHECK): NEW WEL DEEPEN ❑ REOONDITION_ ESTRUCTION❑ J <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 <br /> INTENDED USE TYPE OF WELL Jy <br /> ❑ INDUSTRIAL . ❑ CABLE TOOL Dia.of Well Excavation <br /> ❑,/DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 1�DOMESTIC/PUBLIC ❑ RIVEN Gauge of Casing I <br /> !❑ IRRIGATION RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout Ce&i 0 N <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 04ry P I� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 DA W <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. U1 <br /> Hone owner or licensed agent's signature certifies the following:"I certify that inthe performanceof the work for which this permit lJJ <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractors 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 /> 1 rill ca or a Grout Ins ection prior to grouting and a final inspec lion. <br /> Signed X <666r— Title: Date: •� 2-- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By,, ()q Date <br /> Additional Comments: <br /> se II Gro napeclionPhase III Fir1 Inspection <br /> Inspection By Date ,71-�_g� Inspection By AJ�b-nri Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCEKREMITTEI <br /> REMIT <br /> BASE EXPLANATION DATE DATE AMOUNTDUE CHECKED <br /> ry AMOUNT <br /> PEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _ o� <br /> Received by Date Receipt No. Permit No. Isauanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1111101 E HAZELTON AVE,P.O.eon 21109 STOCKTON.CA 95201 <br />