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Applications Will Be Processed When Submitted ProperlyCo �!$Jpd�e\S'uFeTb- W TIlApqup#lion. <br /> FOR OFf�LCE-USE: APPLICATION <br /> ® (For Non-Transferable, Revocable, SuspeneK 10 198 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITYSAN ~£ `1I tr, U)C'AL <br /> (COMPLETE IN TRIPLICATE) LJ <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct arWrdr t�S1dlf tA§1Wein 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 4331 Homer City/Town ;tockton <br /> Owner's Name Marvin Phone 931.-6360 <br /> Address — � City same <br /> Contractor's Name ' License,,267696 Business Phone 931.-3210 <br /> Contractor's Address —2 Cherry Emergency Phone f <br /> ���--������t��'�e. same � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x. No C> <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMEWEI <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit T 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 /> DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor Moorman I s Water Systems Fa <br /> Type of Pump H.P. 2 <br /> PUMP REPLACEMENT: ❑ State Work Done replace 011pump wit nCPW �51iP <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:A 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which 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 prior to grouting/and a final inspection. <br /> lJ 6V , j�G t X.�/� _ Date: s eo <br /> Signed X Title: "L`L <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Ph a �inI l ection•, ! ,y `cin <br /> Inspection By Date Inspection By Date _ ` <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �{ <br /> —0 HER 3 c*--0 } <br /> 2 1=S1 <br /> Received by Date Receipt No. Permit No. Is uance Date Mailed Delivered <br /> .,P.O.Boa 2005 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE ,-- <br />