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Applications Will Be Processed When Submitted Properly Completed.Be SureTo <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transterable,Revocable,Suspendable) PUMP&WELL <br /> t _ , :. ( <br /> ENVIRONMENTAL HEALTH PERMIT �cc�c�1L— c j <br /> WATER QUALITY e :t. <br /> (COMPLETE IN TRIPLICATE) ` Ct i21t `Cb <br /> Application is hereby made to the San Joaquin Local Health Districifora permit to construct and/or install the work herein described.This aplication is <br /> p <br /> made in compliance with San oaquin,County Ordinance No..1862,and the r les a d regulations of the San Jouin Local Health.District. 1 <br /> Exact Site Address A. Q—A S l,*'Q. X" Z City/Town L c t <br /> i. Phone <br /> Owner's Name dG �` o <br /> f ''r.. t £n .� Cit L a <br /> Address _ <br /> Contractor's Name a e, ` License# F: Business Phone ts' <br /> IL 7AZcl <br /> Contractor's Address f00 �F p `A- c Emergency"Phone <br /> Is Certificate of Workman's Compensation Insurance a on File With SJLHD? Yes° -A No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT ❑Y OTHER 13. -PUMP"INS7ALLA71 �, PUMP REPAIR 0" <br /> REPLACEMENT❑ Pit Priv i t <br /> 'exp i t Sewer Lines # y <br /> DISTANCE TO NEAREST: Septic Tank R r Other <br /> '- <br /> ` Sewage Disposal Fie_ld_- Cesspool/Seepage Pit } <br /> Property Line �aC)` Private Domestic Well POOL' Public Dolnglestic Well <br /> a i <br /> INTENDED USE TYPE OF WELL +., <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavat on Q. <br /> ❑ DRILLED Dia. of Well Casing " Y <br /> 13 DOMESTIC/PRIVATE <br /> ❑ IC ❑ DRIVEN Gauge of Casing i s <br /> i ❑ GRAVEL PACK Depth of Grout Seal t <br /> ,IRRIGATION �. <br /> CATHODIC PROTECTION ❑ ROTARY Type o4 Grout f <br /> El OTHER Other Information <br /> j C3 pISPOSAL i <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> j <br /> PUMPsiNSTALLATION: Contractors '�� ��' <br /> rj' .rtAa 5 E.- . H.P. _240 <br /> ' Type of Pump t ) f <br /> ' � ❑ State Work Done— <br /> El <br /> one - ` <br /> PUMP-REPLACEMENT: � t <br /> PUMP.;REPAIR: ❑ State Work Done t <br /> DESTRUCTION OF WELL: I Well Diameter (c <br /> 1 Approximate.Depth <br /> Describe Material and Procedure <br /> 4 1 t , <br /> OfI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stale 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 thework 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 /> o tractor's hirin tracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> per it issued I shall em y persons subject to workman's compensation laws of C lisof iia." <br /> ��°� f <br /> I ill c Il to ut spec prior to gr ting and a final inspec .. <br /> Signed-X <br /> Title: Date <br /> Draw Plot Plan on Reverse Side) <br /> F.IApplication <br /> FOR DEPARTMENT USE PON{LYj r f� `� Date �!Accepted By <br /> l Comments: has e-I al speciion <br /> - <br /> Phase II Grout Inspection <br /> i y <br /> - Inspection By Date Inspection By f <br /> t1 <br /> Fee IS DUE: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH} ❑ January 1 &Received By January 31 [1 July 1 &Receiv REMITd By <br /> 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> ✓V r <br /> FEE <br /> LESS ' <br /> PRORATION <br /> PLUS . <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 ; <br /> Received by <br /> Date Receipt No. Permit No. - I sue c Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISEAVkCES 1601 E.FIAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95261 <br />