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soh u E USE: / APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable` <br /> l PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 0 <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 r <br /> made in compliance with San Joaquin County Ordinance No.1862 an�d��t/F��a rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address @O'/� l '�^' �e �rJe.tf _T`S _ f o/T�Pt. /VCity/Town <br /> Owner's Name Phone <br /> Address {�D +�Ja� 2.Jlbd� City �S C -e9t <br /> Contractor's Name ✓0 License N /a1j 71T--business Phone —7 G <br /> Contractor's Address .On 9-V C rzti c Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wicd SJLHD? Yes 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 /> IN 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 -��>.�(��®� .,,�L/ S-i �- H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done h <br /> PUMP REPAIR: ® State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure n` <br /> c; <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 wh ich this permi t <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 /> c <br /> I will call for a Grout Inspectio rior to Ming anddaa final inspection. <br /> Signed X1.� ��..• rn Date: <br /> (Draw Plo Plan on Reverse Side) <br /> FORD PARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted Ely 127 Az Date y Q 4 <br /> Additional Comments: 14 <br /> Phase II Grout Inspection Phase III "n I Inspection <br /> Inspection By � Date Inspection By�y_}_ It,.Date <br /> Fee 19 Due: ❑ ANNUALLY ❑ PER UNIT WPER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE LAS I/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt NO P¢rmil 0 s9udn a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16111 E.HAZELTON AVE.,P.O.Box 200 STOCKTON,CA 95201 <br />