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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> FOR OFFICE USE: ! APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) EOLt� A" ER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install thewor.k.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 He th District. <br /> Exact Site Address V3 01- 11 to UJ e.A 1J,0 ����` City/Town _I_A. 7Vaed f G/JC-*oQA/ 16 <br /> Owner's Name ® E L Phone 452F— Q� �I �C� <br /> Address U D d 1 City Ti�v20 Ci4L X0,2�`( <br /> Contractor's Name � ` License# <br /> � Business Phone <br /> Contractor's Address 2-6 2:57 Emergency Phone <br /> CY <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <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 T' 7 <br /> INTENDED USE TYPE OF WELL „ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Weli Excavation <br /> ❑ DOMESTIC/PRIVATEL-DRILLED Dia. of Well Casing y <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing N ho <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal A y� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> CEefl-P 9'h6AL cNN le-Al Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor M <br /> Type of Pump <br /> ❑ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done t <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure A <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 rulestand 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I"certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i! <br /> I wilt calk for a Grout Inspectionrplrior to grouting and a final inspection. <br /> Signed Ttj tL-6INFEL.Df-21S -CS• Title: Date: 21 /914.-[1-I 80 <br /> -+ (Draw Plot Pian On Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> -f zi <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase III Fi I Inspection <br /> Inspection 8y Date Inspection B � � Date <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received.By January 31 - ❑ July I &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE L - ( 3.. <br /> LESS €1 <br /> is PRORATION Sf <br /> r <br /> PLUS <br /> PENALTY t <br /> OTHER <br /> OTHER <br /> Received by Date -Receipt No. Permit No. Issukfnce D to Mailed Delivered <br /> II <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />