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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appiii:ation. <br /> FOR OFFICE USE: _ APPLICATION 7 y_ 7, <br /> (For Nan-Transferable, Revocable, Suspendable) <br /> T — r. PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 862 1 a rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ��Q City/Town �S'Cg1_¢ M, CP <br /> Owner's Name _�� � �� f;-7 I t -C_"_T_O /e Phone <br /> Address V-;--C?2-0 f �` City lf_�_S d M CA, <br /> Contractor's Name (icenfirSY Business Phone ��— G <br /> Contractor's Address Emergency Phone 0 ¢ 9y I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHb? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL E}- DEEPEN ❑ RECONDITION❑ DESTRUCTION-❑ <br /> WELL CHLORINATION C1WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR E] <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank �r� Sewer Lines- % 1 Pit Privy <br /> Sewage Disposal Field A-rd � Cesspool/Seepage Pit Other <br /> Property Line !!V Private Domestic Well '^'r Public Domestic Weilr <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ry (A <br /> B'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing COs <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �;2_ j <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal � z <br /> ❑ CATHODIC PROTECTION ffROTARY Type of Grout �i1.td�rr � <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL s�.. Surface Seal Installed By: ,6�7, _ 1ArC_ - i <br /> PUMP INSTALLATION: Contractor , S r G'• <br /> Type of Pump H.P. <br /> f <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 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 /> 4 t <br /> Contractor's hiring or sub-contra signature certifies the following:"I certify that.i.n the performance of the work for which this ' F <br /> rmit is issued, I shall empl rso subject to workman's compensation laws of California." <br /> , <br /> I ill !I for a Grout ns cfl n p 'or to r ting and a final inrs�pe�ction., - <br /> Signe F Title: tV n r Date: ! r <br /> Draw Plot Plan on Reverse Side) <br /> _ <br /> FO DEPARTMENT USE.ONLY <br /> PHASE Ip <br /> Application Accepted By Da­71 <br /> Additional Comments: r Ii <br /> 1 f Phase I! Grout nspection P"Finalction Inspection By Date _ inspection ByateFee Is Due: ❑-ANNUALLY ❑ PER UNIT =❑ PER SITE ❑ EACH ❑ January 1 &Received Buly 1 &Received By July 31 <br /> ' BILLING REMITTANCE $ REMiT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE d <br /> LESS = ' <br /> PRORATION ( - <br /> PLUS 4 <br /> PENALTY " <br /> OTHER - <br /> I <br /> OTHER ' <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> .•APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box.20o9 STOCKTON,CA 95201 <br /> - — rrn E <br />