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R,.,,... <br /> Applications Will Be Processed When Submitted Properly omp e <br /> ,Fo1FICE use: APPLICATION {' <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install thew ork herein described.This application is <br /> made incompliance with San Joaquin County Ordinance No. 1852 and the rules and regulations of the San Joaquin Local Health Distrflaf, <br /> . <br /> RLane City/Town <br /> Exact Site AddressIR Z5arne i <br /> Owner's Name M Phone 334-9029 c�j- <br /> R city <br /> Address <br /> Contractor's Name .TSR 9r We "Dr <br /> License# Business Phone <br /> Contractor's Address 1 33 Borden R Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�Ii o_ EE l.Oyd <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECOTHER <br /> ITIO N❑P INSTALLATION ❑❑ PUMP REPAIR <br /> WELL CHLORINATION ElWELL ABANDONMENT <br /> REPLACEMENT❑ j <br /> DISTANCE TO NEAREST: Septic Tank 150 1r <br /> Sewer Lines Pit Privy Others — - <br /> Sewage Disposal Field 0+ Cesspool/Seepage Pit53 J <br /> Property Line 12 ft)rivate Domestic Well Public Domestic Well 1; <br /> INTENDED USE TYPE OF WELL <br /> 11INDUSTRIAL ® CABLE TOOL Dia. of Weil Excavation <br /> 12 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 8 tt <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> Depth of Grout Sea <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Inst led By: <br /> k C1GEOPHYSICAL fIt> ;r �i ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ~ <br /> PUMP REPAIR: ! <br /> 13 State Work Done 011 <br /> DESTRUCTION OF.WELL: <br /> Well Diameter Approximate Depth <br /> l 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will C or a Grout I pectin prior to grouting and a final inspection. <br /> j Signed X <br /> Title: Date: A__p"i 1-F1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE Imo" <br /> 1 Date <br /> Application Accepted &al <br /> Additional Comments: t u�Inspection ! a Ill Final Inspection <br /> I. Inspection By Date <br /> Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 July 1 &ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> 1rY1 <br /> 7-6 7 <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by - E <br /> "" APPLICANT—RETURN ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE—P.O-Boa 2009 STOCKTON,CA 95201 <br />