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I 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) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) Y+"LLl�'r' #-+ �* ,�d 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 San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> y Exact Site Address r ' N Ae ^_-' City/Town A 4'?710VrF <br /> Owner's Name �t�2�T �.�/ �,/� Phone �j_ <br /> Address/Z&41,& [/ Is�J`r[`L^ - - City TL <br /> Contractor's Name My I AY Il iF/K License# Business Phone <br /> Contractor's Address Emergency Phane <br /> Is Certificate of Workman's Compensation Insurance n 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❑ F <br /> REPLACEMENT49— <br /> DISTANCE TO NEAREST: Septic Tank "O ItN Sewer Lines— --t Pit Privy <br /> Sewage Disposal Fieldi „t�C Cesspool/Seepage Pit Other <br /> Property Lineae+' ellPrivate 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 /> 'IRRIGATION <br /> ❑ DRIVEN Gauge of Casing <br /> �F IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL "❑ OTHER Other Information <br /> i <br /> ❑ GEOPHYSICAL ”= _Surface Seal Installed By: ` <br /> PUMP INSTALLATION: Contractor ✓ - <br /> I:Type of Pump L Y1/9 r sm�C-[ P. <br /> I PUMP REPLACEMENT: P-State Work Donee <br /> PUMP REPAIR: i❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r Describe'Material and Procedure �d <br /> k 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 /> 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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout47;f�ionprior to grouting and a final inspect'Signed X /a"7 : Title: v Date: <br /> { (Draw Plot Plan on Reverse Side) <br /> }. FOR DEPAR MENT USE ONLY <br /> L <br /> PHASEI F <br /> Application Accepted By = -^ Date <br /> Additional Comments:.. Al <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT PER SITE 13EACH ElJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> : BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION REMITTED DATE DATE <br /> t AMOUNfi <br /> i• FEELESS <br /> PRORATION 1 �� <br /> PLUS <br /> PENALTY ``-4 <br /> OTHER <br /> OTHER .1 <br /> Received by Date '`. Receipt.No: Permit No. Issuance Date Mailed . Delivered <br /> r APPLICANT—RETURN ALL COPIES TO:,&ENVIRONMENTAL HEALTH+PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 052x1 <br /> " .- <br />