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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&WELD"' <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> (COMPLETE IN TRIPLICATE) I WATER QUALITY ,. <br /> Application is herebypade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Countyinance No. 1862 nd the rules and regulations of the Sari Joaquin Local Health District. i <br /> Exact Site Address :!� J.OrdCity/Town MAC) <br /> Owner's Name F/o ✓/ / Phone <br /> 'l <br /> Address i� Ap r City F4 C <br /> Contractor's Name G+b S}QN tdJ�j1 Ri{ l� License#3 7Q a Business Phone 759– �.?77 {n3 r <br /> Contractor's Address J70, k -S Emergency Phone _5 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN1jr RECONDITI.ONW DESTRUCTION❑ I` <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATION 11PUMP REPAIR❑ <br /> D ' <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Sep is Tank A 7 Sewer Lines 67 Pit Privy <br /> F sewage Disposal Field !C Cesspool/Seepage Pit �— Other --� <br /> Property Line/4.1�10 Private Domestic Well ; "Public Domestic Well ! F <br /> INTENDED USE TYPE OF WELL o 11 If <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casingy <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing o ,5• " <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal l-3 IN4 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information �1 <br /> t ❑ GEOPHYSICAL Surface Seal Installed By: 5_4" - <br />)° PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 /> r ordinances, state Iawsland 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 /> 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 c 1 for a Grout Inspect11 'on prior to grouting and a final inspection. <br /> i <br /> Signed X <br /> ,�. <br /> DaterTitle: <br /> (Draw Plot Plan on Reversme <br /> Side) + <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By °'� <br /> b Date 13 <br />[ Additional Comments: _ <br />[ Phase it Grout spection Kase II Inspecti I�,fnr-it� <br /> I <br /> Inspection By Date Inspection By (3"� ` -3 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El- ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE BILLiNG REMITTANCE $EXPLANATION PATE DATE REMITTED AMO NT DUE CHECKED <br /> �j I AMOUNT <br /> FEE' � .� <br /> LESS I� <br /> PRORATION <br /> PLUS <br /> E PENALTY <br /> OTHER I� <br /> OTHER ' <br /> Received by - pate' Receipt No. Permit No. ,4 Issulance Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />