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FOR OFFICE USE: APPLICATION = . <br /> (For Non-Transferable,Revocable,Suspendable) <br /> PUMP&WEE—L ' <br /> •� - ENVIRONMENTAL HEALTH PERMIT <br /> �n w �QuAUTY 0�7-0t10--0J <br /> (COMPLETE IN TRIPLICATE) 6 �0 �•,•k� <br /> Application is hereby madetotheSan Joaquin Local Health Distric ora errnitto construct and/or install thework herein described.This application is <br /> made in compliance'with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address/f Xde f ii Q911,-&0"r �e �' �A•v fJ_ City/Town <br /> Owner's Name v 04 <br /> Phone Q 3 <br /> IL <br /> Address `. City <br /> Contractor s Name v/v4 License#o�� Business Phone � � ;�,�. t <br /> Contractor's Address Emergency Phone _ _ V-"n <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR19— <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> ems- L Sewer Lines �..y �� Pit Privy <br /> Sewage Disposal Field_( 0 a Cesspool/Seepage Pit _.A(,�j_ Other <br /> Property Line. Private Domestic Well,&✓'a�Public Domestic Weil <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 /> R RIGATION ❑ 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 0"-zvegS a mu A A <br /> Type of PumpH. - <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 01"Mate Work Done IZ9 - ' � y <br /> DESTRUCTION OF WELL. Well Diameter Approximate Depth <br /> J <br /> Describe Material and Procedure —' <br /> 1 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:"1 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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> ell <br /> Signed X Title: Date: Z Z, <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By `y""� 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 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE . $ AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> Received by Date Receipt No. Permit No. f Issuancle Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O_Box 2009 STOCKTON,CA 95201 <br />