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4 <br /> Applications Will Be Processed When Submitted Properly Completed_Be Sure To sign the Appncatio, } �, <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendebie) PUMP&WELL, <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY 2O —(/o --C O d <br /> (COMPLETE IN TRIPLICATE) Zte- <br /> _ Application is hereby made to the San Joaquin Local Health District fora perm ittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis f <br /> made in compliance with Sa Joaquin County Ordinance No. 1862 and the r�les ��regutior}sv oth5an Joa n Local ealth 91stric <br /> /�.- Gy Cs�-r►�r d fr �� ( t7 lMfk�C 194"`' <br /> Exact Site Address� .,lo <br /> r /� f — 0 <br /> Owner's Name/ � f�re P ,vnl'I�` Q 06-- fa4 Phone <br /> Address —fQ1�Z� �' - —�=,� — City- }�-- i <br /> License * Business Phone_ S��-7 <br /> Cr <br /> Contractor's Name � � <br /> Contractor's Address _3(?a i ff Emergency Phone ___& `7�? <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> _ No v <br /> TYPE OF WORK (CHECK): NEW WELL. DEEPEN 13 RECONDITION21—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 Fi Id Cesspool/Seepage Pit _ Other <br /> Iff Property Linerivate Domestic Well 'C•`—' Public Domestic Well <br /> INTENDED USE TYPE OF WELL I <br /> l <br /> i ( I <br /> t ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> XDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> 11 DRIVEN Gauge of Casing jQ <br /> GRAVEL PACK Depth of Grout Seal AFO ---�; <br /> ❑ <br /> IRRIGATION ..t <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout U�---- I <br /> ❑ DISPOSAL ❑ OTHER Other Information w a' <br /> ❑ GEOPHYSICAL Surface Seal Installed fay: aW 4 ei- _ <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> f <br /> PUMP REPAIR: 11State 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 ) <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:"I certify that in the performance of the work for which this 4 <br /> t permit is issued. I shall employ persons subject to workman's compensation laws of California." <br /> I wlll or a Grout Inspection prior to grouting and a final inspection. <br /> Title: <br /> Date: <br /> Titl <br /> I Signed X Draw Plot Plan on Reverse Side) <br /> ' FOR D ARTMENT SE ONLY q <br /> PHASE I Date / <br /> Application Accepted By-- <br /> Additional Comments: <br /> Phase 11 Grout inspection Phase I11 Final Inspection <br /> Date Inspect on By C -Date Z tO <br /> Inspection <br /> &Rec y January 31 ❑ Ju.y I ft Received By July 31 <br /> F Fee Is Due: ❑ ANNUALLY IIuJJ PUNIT ❑ PER S- ❑ ERC anuar❑ y 1 REMIT <br /> ER <br /> BILLING REMITTANCE b AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER Ci <br /> -7 'V <br /> Date L Receipt No. �� Permit No. - Issuance Date. Mailed Delivered" <br /> ' Reserved by ' <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERV4CES 1601 E.HAZELTON AVE., .O--iscit 609 STOCKTON,CA 5201 <br />