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:I�Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE:!� 4 1 � APPLICATION <br /> !� (Q✓h (For Non-Transferable, Revocable,Suspendable) PUMP&WELL (/ <br /> I� ENVIRONMENTAL HEALTH PERMIT <br /> II <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> :I <br /> made in compliance With San Joaquin County Ordinance No.1862 and the rules and regulations of the San_ Joaqulip ocal Health District. <br /> Exact Site Address :l T21, e- L 104� City/Town .� <br /> Owner's Name �_H' k. ge � Z'/^^�_r, �% - Phone <br /> Address !M "77 y- 'x -. !7!aiib City <br /> Contractor's Name :�h� k `License#/W -7Ti Business Phone <br /> Contractor's Address!p _ Emergency-Phone =tet err - I <br /> Is Certificate of Workman's Compensation Insurance on File WI SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL'❑ - DEEPEN 11` ' RECONDITION❑ - DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT.O OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ 11 4 <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 1 <br /> INTENDED USE TYPE OF WELL I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 0 DOMESTIC/PRIVATE C1 DRILLED Dia. of Well Casing <br /> ElDOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> El IRRIGATION !1, ❑ GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL C3OTHER Other Information <br /> ❑ :GEOPHYSICALl� Surface Seal Installed By: <br /> .T <br /> PUMP INSTALLATION:. Contractor <br /> �. Type of Pump ` v :. .� .. H.P.- Lam✓ <br /> ` PUMP REPLACEMENT: I& State Work Done -Pr� �I� - 0r4z/ - <br /> PUMP REPAIR: it IJ State Work Done r-r.i <br /> I DESTRUCTION OF WELL: Well Diameter t 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 /> ordinance'sstate 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,•SII shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contract is 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 /> li' a <br /> I will call for a Grout Insp n pylar outing anfl.,, final inspection. <br /> f <br /> Signed Xc l le: = x J Daie: <br /> I� (Draw Plot �an'ton Reverse Side) <br /> } FOR DEPARTMENT USE QNLY <br /> PHASE iy /� Q } <br /> } Date <br /> Application Accepted 8y f <br /> Additional Comments: <br /> Phase I Grout Inspection PhWe II incl Inspection q <br /> l <br /> Inspection! <br /> By Date ''rt Inspection By Date _ !�Z Z^gV <br /> Fee is Due: ❑i ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receiv-d'13y January 31 ❑ July 1 &Received By July 31 <br /> !� REMIT Y- <br /> BASE -EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE �� - <br /> LESS a s <br /> PRORATION Y I� <br /> PLUS I .. <br /> PENALTY J <br /> ' OTHER - <br /> OTHERI�' - <br /> 'IIIILII <br /> Received by bk _.Receipt N Permit No. Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE_,P.O.Box 2009 STOCKTON,CA 95201 <br />