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�. FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 wi S`2n,jQaquin�,o`pty O•^din �e�NNo 2 anq,+ ;,eJles and regulations of the Sans Joaquin -co I Healistrict. <br /> Exact Site Address Ip S U (,J 1 L7 i' I/c (� City/Town ?U - <br /> Owner's Name — T _ Phone —_101 3 <br /> Address nn SCS ! _ City T?M C!C 113 <br /> Contractor's Name •Lr V ense H Business Phone f Z <br /> Contractor's Address Z.. IVCJairinA With gency Phone ^J6 <br /> Is Certificate of Workman's Compensation Insurance on Fie With SJLHD7 Yes No <br /> TYPE OF WORK(CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR U, <br /> REPLACEMENT❑ „ , /�/(dF Li�, E <br /> DISTANCE TO NEAREST: Septic Tank '4 3� 'S't3wnes Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other C <br /> Property Line Private Domestic Welt_ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED pie.of Well Casing _ a <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 r <br /> PUMP REPAIR: State Work Done L�,+ r , 7A.,6 <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 /> Home owner 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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I II I r t ns dor outing and a final Inspection. <br /> Signed X Title: L/ • �+ Data: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR)DEPARTMENT USE ONLY <br /> � PHASE I <br /> Application Accepted By Dat 77 ? <br /> Additional Comments: <br /> Phase II rout Inspection phase III Final Inspection <br /> Inspection By Date Inspection ByDate _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 13 EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE j REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 1 j <br /> LESS 7 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O Z5 <br /> _ =74-9u <br /> Received by Date Rewipt No. Permit No. Issuance Dele Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.S0e 29119 STOCKTON.CA 95301 <br />