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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE use: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) l <br /> PUMP&WELL <br /> _ ENVIRONMFA <br /> T L HEALTH PERMIT <br /> «: r d <br /> (COMW'LETE IN TRIPLICATE) f T QUALITY A" <br /> L <br /> Applirailtonishereby made tothe SanJoaqu•inLocalHealthDist ctforapermittoconstructand/orinstal hework herein esc e �~ ID70N� <br /> ' d.This application is <br /> made iF, mpliance with San Joaquin County Ordinance No. 1862 and the r les anc� regulations of the San Joaquin Local Health District. <br /> Exact Site Address �90 E d�Lo '� �i /1 /7O 077 <br /> ff City/Town _ ,L D DI <br /> 04ner's'�Vame G DGE. F3E`LL. / <br /> Phone <br /> Address 310 TAY ST City <br /> Contractor's NameLicense#X370 Business Phone t p <br /> Contractor's Address _.7P D 75 p r' /_. A4C-7V 45; mergency Phone —54-. ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�_ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 11 RECONDITI ON <br /> ❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ O HER © PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT 11Z'A41q J94 got,-f--h a L <br /> DISTANCE TO NEAREST: Septic Tank 1 9� 1.— Sewer Lines pit p <br /> Sewage Disposal Field of/Seepage Pit� �, O <br /> Property Line_ /S Private Domestic Well Pu Other <br /> lic Domestic Well then <br /> INTENDED USE - TYPE OF WELL 8�» <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> .."4 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing v <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Oma` <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 9 54'r,1-4 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - <br /> Surface Seal Installed By: /[,[/,�� <br /> PUMP INSTALLATION: <br /> Contractor 1' <br /> t - . <br /> Type of Pump H p <br /> PUMP REPLACEMENT: ❑-State Work Done <br /> PUMP REPAIR: ❑�State Work Done T . <br /> DESTRUCTION OF WELL: We11 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 /> 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 shalt not employ any person in such manner as to become subject to workman's compensation laws of California," f <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this r-i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed XQ,� 110, <br /> �`"` Title: �7`w-L Date: <br /> —.,(Draw Plot Plan on Reverse Side) T <br /> FOR DEPARTMENT USE ONLY t/y1 �' <br /> PHASE I l I I <br /> Application Accepted By Date - <br /> Additional Comments: <br /> ha a 11 Grout Ins ction Phase 11 Final Inspection <br /> Inspection By ate 7!!f Inspection By.� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE -❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATEDATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE . • d a <br /> LESS <br /> PRORATION . t <br /> PLUS <br /> PENALTY - <br /> OTHER t { <br /> OTHER <br /> d ��_&:S� <br /> Received by Date Receipt No Permit No, I seance ate Mailed Delivered z <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA 95201 <br /> t <br />