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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .E;E USE: APPLICATION / <br /> (For Non-Transferable,Revocable,Suspendal� <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 with San Jo�`quin County r�finance No. 1862�d th�r les and oft a San Jaguin Local Health District. <br /> 0911 <br /> Exact Site Address�d ,S�dt �R.v //�N d MJ Se, <br /> yl 6cA'`V y <br /> Owner's Name n Phone 9190 L - 57 y 77 <br /> AddressCity <br /> Contractor's Name %1Licensel! Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank �() f4- Seer Lines 9;�(� `{ Pit Privy <br /> ol/ <br /> Sewage Disposal Fi7ld /dy CesspoSeepage Pit Other <br /> Property Line/(? -f Private Domestic Well :5a—E 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 , i Y �� <br /> 11DOMESTIC/PUBLIC C1 DRIVEN Gauge of Casing c• n-^,r �t19L�1E�/ <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: mrioz <br /> J <br /> PUMP INSTALLATION: Contractor II AC7, <br /> Type of Pump C_ .y Jj 6, H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done N <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 /> 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 J <br /> permit is issued, I shall employ persons s ject to workman's compensation laws of California." <br /> I will or a Grout spec on pri "r t grouting and a final inspection. t <br /> G <br /> Signed X Title: 41qxv Date: <br /> (Draw Plot Plan on Revue ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By,,\iFDate �J <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> Inspection By- Date Inspection By �1 ' Date Z� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS te <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6���0 1� <br /> Received by Date Receipt No Permit No. Iss ance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95201 <br />