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Applications,Will;BeFlrocessed When,Slobmitted Properly Completed.Be Sure ToSignTheAppncarlon <br /> r-; , . , i, • i� til <br /> 1 ' tj PPLICATION <br /> F)R OFFICE USI-: <br /> l � � For Non- r�d erabte, Revocable,Suspendable). 1 PUMP&WELL <br /> - — t..j <br /> DEC �� 4�{'y�RONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) rs�� WATER QUALITY <br /> �`I I= I IrDt�liL•"ocalF�ealt sf Ctfora perm'sttoconstructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> Application is hereby made to theShMadui <br /> made in compliance with San Joagl�t�_cS)unt} brdi'4666� 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ���3C .Se. City/Town <br /> Owner's Name L"Oe z2o2 �, Phone 7 �� <br /> Address <br /> J ' [. City„ <br /> Contractor's Name nexe License# .IK_ �cr 11K$Kw_ Business Phone_�Zgq <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❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR �3 <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 /> MIDOMESTIC/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 i! i.f! H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done C <br /> PUMP REPAIR: tate Work Done �' 'E ' G V <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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." 1 <br /> "Contractor's hiring or sub-contracting signature certlfies the following:1 certify that in the performance of the work far which this <br /> permit is issued, I shall employ persons qubject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. - <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY l <br /> PHASE I Al/ . p�-- DaJ12- <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Ph se NI Pinal Inspection Z <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ AN ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> {� DATE DATE REMITTED AMOUNT <br /> FEE <St4Is <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by ate Receipt No. Permit No. Issuance Date Mailed - Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Boz 2009 sTOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />