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T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. k <br /> FOR OFFICE USE: APPLICATION <br /> {For Non-Transferable, Revocable, Suspendable) PUMP&WELL J <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe 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 /> Exact Site Address �- � ) �� -`t City/Town t--DX. <br /> Owner's Name .�►� <br /> b S Phone 3& 9 S ;2~7 <br /> Address ._214 W' - City. 1. ODa- <br /> Contractor's Name M Ojr �� License# X770440 Business Phon — 2 <br /> Contractor's Address '2- <br /> Zy�N 7A e�� Emergency Phone N f-I'"r '1 LA 2-4 � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—"XNo <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> i <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ,�❑,/DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> .IKIRRIGATION 13-GRAVEL PACK Depth of Grout Seal <br />' ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information t. <br /> ❑ GEOPHYSICAL p Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r r�OYt% 6 �. <br /> I <br /> Type of Pump kU I n,1;_" <br /> PUMP REPLACEMENT: ❑ State Work Done '��L�` �Ci!W 0W <br /> I PUMP REPAIR: State Work Done M <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth •[ <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 /> Home owner 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 st nature ce 'ties the following:"I certify that in the performance of the work for which this <br /> permit is issued. I shall epvy pers s subjec o workman's compensation laws of California." <br /> t <br /> I call or a: o t 1 coon for to gr ting and a final inspection. <br /> Date: a <br /> Sign Title: , <br /> { aw Plot Plan on Reverse Side) <br /> FOR EPARTM T USE ONLY <br /> t PHASE I / 12- <br /> Application <br /> - 3�7� <br /> I Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase Ill Final Inspection <br /> Inspection By Date nspection By Date <br /> w <br /> Fee IS Due: 11 ANNUALLY ❑'PER UNIT ❑ PER'SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I. REMIT <br /> RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> S <br /> i <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> Received by Hate Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />