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App:ications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FO FFICE USE. APPLICATION <br /> N V (For Non-Transferable, Revocable,Suspendable) <br /> �r ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> _ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Applicationishereby madetothe San Joaquin Local Health Districtforapermit toconstruct and/or install the work herein described.This application is 11 <br /> i <br /> made incompliance with San Joaquin Coun Ordi � ce N-yoe..1862 and t e rules and regulations of the San Joaquin Local Health District. <br /> Exact S'Iite Address �Je _ Oity/To.17;7 dos� <br /> wn <br /> Owner's�Name Phone <br /> Addressl: City <br /> Contractor's Name _•.++11 Licenstf 9;(Z Business Phone_", r <br /> Contractor's AddressEmergency Phone L <br /> I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Lam- No <br /> TYPE OF WORK (CHECK): NEW WELL B' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> ,.r•�r _ r a ssn-n��,., r?1. 1SQ '11R gni r ATLnJyi. of k P_q�oe�Qn <br /> ;M <br /> - -- - ------------------------------ <br /> W"titer Supply: Pubjic system ❑ Community syystem ❑ Private1,{ ] Depth to Water Table��- ft, <br /> l I Sewage Disposal Field A&a4P cesspool/seepage Pit Other <br /> Property Line-_2_,z Private Domestic Well ublic Domestic Well <br /> IN TENDED USE TYPE OF WELL �l <br /> ❑ lNDI RIAL El CABLE TOOL Dia. of Well Excavation f <br /> x <br /> OMESTIG/PRIVATE 13 DRILLED VDia. of Well Casing SAY <br /> ❑ DOAESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f <br /> ❑ IRRIGATION ❑ GRAVEL PACK .,,Depth of Grout Seal D � <br /> ❑ CA T11HODIC PROTECTION &-ROT [Type ype of Grout .� <br /> ❑ DISPOSAL 11 OTHER Other Information Q <br /> 11 GEOPHYSICAL Ji Surface Seal Install By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 577 [� <br /> PUMP REPLACEMENT: © State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTA' CTION 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. r <br /> ' <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 torwhich this <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." - <br /> I w=cforroutInspection prior to grout1jW d a final inspection. IN <br /> 1 Signed X Title: Date' r <br /> II (Draw Plot Plan on Reverse-Side) <br /> y i R DEPAR MENT USE ONLY <br /> )PHASE I <br /> I�Application Accepted By - <br /> Additional Comments: 6inahfrts' <br /> I Ph se II Grout Inspection P se 111 pection <br /> i <br /> Inspection ByOat e �y Inspection By Date x <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I REMIT, ' <br /> BASE EXPLANATI N <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKL6-- <br /> I DATE DATE REMITTED #}, <br /> . �1'. AMOUNT <br /> I <br /> )FEE P — <br /> IESS <br /> PRORATION <br /> JPLUS <br /> PENALTY _ <br /> I�I� - <br /> .OTHER e '1 <br /> IIOTHER' - <br /> ill 7 i S j—.11 ami Yli 79 <br /> -�- IReceived by Date Receipt No. Permit No. Issuance 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 />