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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appiicat_io�. <br /> '.AoR bF.ICE USE: // ff APPLICATION pldf <br /> ,'�' %" " <br /> �ofj (For Non-Transferable, Revocable, Suspendable) <br /> - ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 /> made in compliance with San Joaquin County Ordinance No. 1862 and he rules and regulations of the San Joaquin o al.Health District. <br /> Exact Site Address ly dZ� -S �}�G?-L.S�„- � City/Town <br /> Owner's Name Phone <br /> Address __ S1 L] _S" L�Ct!.S'iL I✓ City CS <br /> Contractor's Name 4e*jG b`1 cs License#)5'37 Y�s�Business Phone L AY -R 7lr <br /> Contractor's Address oea1. w Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ V4 j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ ,� I <br /> DISTANCE TO NEAREST: Septic Tank j Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL + <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Welt Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ 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 /> C1 DISPOSAL ❑ OTHER _ Other Information <br /> ❑ GEOPHYSICAL uk surface Seal Installed By: <br /> r _ <br /> PUMP INSTALLATION: Contractor ZF_ f"49 <br /> Type of Pump —7—m -A ii H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done k 7Z� % <br /> PUMP REPAIR: ❑ State Work Done 72AJ Ib <br /> DESTRUCTION OF WELL: Weer At J01 -ue ® <br /> Describe Material and Procedure A" 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f <br /> ordinances, state 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, 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 /> r <br /> I will calf for a Grout Inspect' p or-t ro ting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPART ENT USE ONLY <br /> PHASE I <br /> Application Accepted By kL/r"` "` Q Date C �•� <br /> Additional Comments: <br /> —PKfise 11 Groui Inspection Rhpse III Final Inspection <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 Juiy 31 <br /> 1 BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> l' AMOUNT <br /> FEE <br /> LESS § 4 <br /> PRORATION 11 <br /> PLUS - - A <br /> PENALTY <br /> OTHER <br /> - a <br /> OTHER — - <br /> . <br /> Received by .. - Date , Receipt No. ,Permit No. Issuance Date Ma0ed Delivered JJJ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 116011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />