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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&WALL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> A <br /> p �icationishereby made tothe San Joaquin Local Health District for apermittoconstruct and/or install the work herein described.This application is <br /> 2a 'in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> CIs <br /> act SiteAddress Ht I I� �t• City/Town <br /> wner's Name Don A. Cose Phone 836-0422 <br /> dress 19 E. .6thSt City TraCK. Ca. <br /> ontractor's Name 17on A_' Cole License# 276362 Business Phone 836-0422ontractor's Address '�9 E6th qt- Emergency Phone <br /> Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIOU* 'Z) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank S r Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> t Property Line �PEOF <br /> ate Domestic Well Public Domestic Well <br /> INTENDED USE WELL <br /> ❑ INDUSTRIALif CABLE TOOL Dia. of Well Excavatio <br /> 13DOMESTIC/PRIVATE [J DRILLED Dia. of Well C ' g <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge asing <br /> ❑ IRRIGATION ❑ GRAVEL PACK D of Grout Seal <br /> ❑ CATHODIC PR CTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOP ICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> I <br /> T; te <br /> of mp H.P. <br /> PUMP REPLACEMENT: ❑ Work Done <br /> IPUMP REPAIR: iI ❑ St <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> h Describe Material and Procedure <br /> q C:I hereby certify that I-have prepared this application and that the work will be done In a JDa uin 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 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 /> Contractoes hiring or' b-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit ' ssue I employ persons subject to workman's compensation laws of California." <br /> I G n tion prior to grouting and a final inspection. <br /> Signe / ris Title: GDate: 7�28�80 <br /> Signed LH <br /> % (Draw Plot Plan on Reverse Side)- ... . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By `' Date <br /> Additional Comments- <br /> ha Inspecti h I nal spection <br /> Inspection By Date Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> I BASE EXPLANATION AMOUNT DUE CHECKED <br /> 6 DATE DATE REMITTED AMOUNT <br /> FEE LA a L13 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> —7— LAt o cam- )I_.EZ <br /> Received by Date Receipt No. Permit No Issuance Date -Mailed Crplivered <br /> APPLICANT—RETURN ALL COPIES:TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />