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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE.USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Sarna Joaquin County Ordinance No. 1862/and the rules and regulations of the San Joaquin Local Health District. _ <br /> Exact Site Address . � —�!a!V"7 gj^1rq fC j� City/Town AL04 <br /> Owner's Name i Ly q os z i Phone <br /> Address �1�I r) P Ajwk7T �/Ae� JeD City <br /> Contractor's Name ��r -r-N 1miv, d : ?a3 °ls` ,— License# 2 / Business Phone l <br /> t Contractor's Address52sEmergency Phone <br /> Is Certificate of Workman's CompensationIns ranee 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 REPAIR❑ <br /> REPLACEMENT❑ j � CCl <br /> y DISTANCE TO NEAREST! Septic Tank � Sewer Lines - Pit Privy ti <br /> k =.� Sewage Disposal Field 1 `-Cesspool/Seepage Pit Other <br /> t <br /> Property L`ne . Private Domestic Well's Public Domestic Well r <br /> INTENDED USE TYPE OF WELL / 11 IJ) <br /> 1©+INDUSTRIAL ❑ CABLE TOOL-` Dia, of Well Excavation <br /> u� <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing l 0 <br /> i 11IRRIGATION GRAVEL PACK Depth of Grout Seal I _ <br /> ❑ CATHODIC PROTECTION )d ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> t Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑-StateWork Done � - w <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 'Describe Material and Procedure ' e <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 /> 1 <br /> -ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> j <br /> Homeowner or licensed agent's signature certifles 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 <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California." 3 <br /> I will call fora qwput inspection prigrto grouting and a final ins'pecti'o <br /> Signed X f -�" '4 Title: J Date: C <br /> I (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I )� <br /> Application Accepted By— Ay—c e,_ 07 <br /> - - Date <br /> Additional Comments: <br /> . hase I Grout Inspection j Phase III Final Inspection <br /> Inspection By Date — Inspection By Date <br /> l <br /> I Fee Is Due: [33 AN ALLY PE 1It' �uA C_SITE - EA H Januar 1 8,R ceived By Jan ar \ , July 1 8 Received By July 31 <br /> . REMIT <br /> BASE EXPLAN AT J '$� p»- '.y�y�F-'T DUE CHECKED <br /> T <br /> II f� AMOUNT <br /> FEE <br /> LESS � �p� 4 ��� ` A— / <br /> PRORATION <br /> FLUS" — <br /> W PENALTY ~� <br /> OTHER <br /> OTHER <br /> Received by ;Date Receipt No Permit No. issuance Date Mailed Delivered <br /> k <br /> 'APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES - .. 1601 S.HA2ELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />