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FOR OFFICE USE IYINY u Z) 1JOU APPLICATION <br /> 'For Noe-Transferable, Revocable, Suspendable' <br /> SAN JVAQL.4 LOC-AL NMENTAL HEALTH PERMIT PUMP&WELL <br /> HEALTH D{ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 an J4act i County 9rdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 349 - City/Town 1�e fC <br /> Owner's Name Phone <br /> Address City— C-y <br /> Contractor's Name r'iMoh, S License# 10 Business Phone�� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRZ <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 /> ❑ 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 �^I pp Su ra/ ce Seal Installed By: Q <br /> PUMP INSTALLATION: Contractor 14 /7le A- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done (A <br /> PUMP REPAIR: 10 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 fib, <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 forwhich 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 will ca/II forr Groo,W/l�spection prior to grouting and a final inspection/n <br /> Signed X . 7 A .2 • -..JL Title: -,1-14A�L�.,/ Date: <br /> �r (Draw Plot Plan on Reversetide) <br /> FO EPA MENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Re ive By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> /',CC 04/6 <br /> � r AMOUNT <br /> FEE T v 7 V <br /> LESS <br /> PRORATION j <br /> PLUS 2() <br /> PENALTY dr <br /> OTHER <br /> OTHER <br /> '5' .fig 3'6 33-7,;), <br /> 4 5 SaS s �v <br /> Received by Date Receipt No. Permit No. Issuance Date Mailetl Delivered <br /> APPLICANT—aETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Soa 2009 STOCKTON,CA 95MI <br />