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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&wEl_L <br /> = ENVIRONMENTAL HEALTH PERMIT } <br /> •+ � <br /> (COMPLETE IN TRIPLICATE) WATER'OUll`LITY <br /> Application is hereby made to the San Joaquin Local Health District for a 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 /> Exact Site Address 13 ,5910 ��'�' ��'�-� City/Town z-1e e <br /> Owner's Name � � * Phone �p <br /> Address — c -m-e_- w r City J9�r. axas7 r✓ �i t�,. <br /> Contractor's Name E Pdi.1�11*- License#�6,:;; Business Phone c?"?7 <br /> .*. Emer enc Phone ' <br /> Contractor's Address r 9 y <br /> Is Certificate of Workman's Compensation insurance on File With SJLHO? Yes lkr No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ -- - r <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER ❑ -PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ F <br /> DISTANCE TO NEAREST: Septic Tank t Sewer Lines s Pit Privy <br /> Sewage Disposal Field JZa Cesspool/Seepage Pit -&- Other `" <br /> Property Lined Private Domestic Well ; F Public Domestic Well <br /> INTENDED USE TYPE OF WELL .1 ��1 _c <br /> El INDUSTRIAL ❑!CABLE TOOL Dia. of Well Excavation � <br /> DOMESTIC/PRIVATE _9IDRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing s .4e i <br /> ❑ IRRIGATION yGRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION MIROTARY Type of Grout acs a- s r' f r�' ►�Csa� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �1oA <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H•P•...- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 0#State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> " I <br /> 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 Grout Inspection p 'or to grouting and a final inspection. ! <br /> t <br /> Dale <br /> Signed Title: Date-. -7 <br /> (Draw Plot Plan on Reverse Side) <br /> s � <br /> ? <br /> 4FORZDPARTMENT USE ONLY <br /> PHASEI <br /> .. Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout inspectionF Phase III Final Inspection �7 <br /> Inspection By Date 13 Inspection By 1c, e Date <br /> y„ .:• <br /> •' ;❑ January 1 &Received By January 31 ❑ July 1 8 Receivetl By Juiy 31 <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT 9-PER SITE 11 EACH; <br /> ^- f- : - - REMIT <br /> BASE EXPLANATION BILLING ";`,-.;.F&jITTANCE - $ AMOUNT DUE CHECKED I <br /> - DATE a' r.';"-DATE REMITTED <br /> AMOUNTi <br /> FEE 3' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ q <br /> OTHER <br />' OTHER - <br /> Received by Date Receipt No: Permit No. Issuarice Dat ""Mailed Delivered <br /> - 'APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201 <br />