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Applications Will Be Processed When Submitted Properly Completed Qq'�ure To Sign The Applicatioq. <br /> FOR OFFICE USE: APPLICATION �L'1 APR <br /> (1 r1 n VM <br /> (For Non-Transferable, Revocable, Suspendable) APR 9 1980 <br /> ENVIRONMENTAL HEALTH PERPUMP&WELL <br /> MMAN JOAQUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1882 and Ws s and regulations of the San Joaquin Local Health District. <br /> Exact Site Address //s�s 1!g96 S'. ya M pJ.J,1W City/Town <br /> m��SC /O,Cp�✓ 00 <br /> Owner's Name rXS n N gig ti�/�L� Phone <br /> ��� } <br /> Address �+�^-�• City �G ' <br /> Contractor's Name Aj License Bu `ness Phone am iI207 <br /> Contractor's Address '? on3 0077, i/ Emergency Phone isE..--ems06 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD9 Yes 4044 No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN❑ RECONDITION 13 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 Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> Ia DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ 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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done C_^A yg =7SA*-2z Sr <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 <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 /> ContracYoYs hiring or aub-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�all/fJ/�r�Ml_a G ton prior to grouting and a final Inspection— <br /> Signed X _ Title: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By 0 Date <br /> Additional Comments: <br /> Phase 11 Grout Inspectional Inspection <br /> Inspection By Date Inspection B P e nDate `- e ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July I &Received!By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATIONBILLING <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 41 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by I Date ReOeipt No. Permit No. Issuance Data Malleo Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HA N!LTON AVE.,P.O.Bw 2009 STOCKTON,CA <br />