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Applications Will Be Processed When Submitted Properly Completed. Be SuremA.epn The Application 4L j�'f /�` <br /> FOR OFFICE USE: APPLICATION AP{t j j �► <br /> (For Non-Transferable, Revocable, Suspendable) 19 <br /> ENVIRONMENTAL HEALTH PERMIT S%}N Jn PUMP WELL 1 <br /> OUtfV LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY N Lrj'lD1S RlgT, <br /> r(;��-- _F <br /> Application is hereby madetotheSan Joaquin Local HealthDistrictforapermittoconstruct and/or installtheworkhereindescribeed. s application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. I <br /> Exact Site Address 1!") % 14Z/ 50 1) Z__A4-1E, City/Town <br /> Owner's Name Phone <br /> Address - e?ki ZQ —_.. City <br /> Contractor's Name 14EW l IA L. Z,dA_.. License# Business Phone_��C�g� - a <br /> Contractor's Address 5- Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q <br /> e,�lJrri�s'iddf7iF1'" J-1 A�_!.�. � ., �� 'J. �c _P 1"'1 n <br /> "r a u e55 �':' nC.s 'Prlbtf$.,� .. <br /> Contractor's Name U License No. J �_6-6 Phone G ]J <br /> Sewage Disposal Field Cesspool/Seepage Pit —10Z2- - `"Other <br /> 1 <br /> Property Line 2-5 Private Domestic Well /0<5 Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> /i <br /> ❑ INDUSTRIAL l ❑ CABLE TOOL Dia. of Well Excavation 61 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 1 ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION K ROTARY Type of Grout b �� <br /> ❑ DISPOSAL t El OTHER Other Information y �r <br /> LGEOPHYSICAL�rGe 6_� _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT-, ❑ State Work Done <br /> PUMPyREPA#R ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r 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. <br /> Home owner 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 calf for a Grout In on prior to grouting and a final inspection. <br /> Signed X Title: A, Date: Z5�/40PL <br /> / Draw Plot Plan on Reverse Side) I� <br /> L— FOR DEPARTMENT USE ONLY <br /> PHASE 1 �) <br /> 2 Application Accepted By A��'�—o..� Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspec� <br /> Inspection By D� I- ept,on By Date <br /> L 1� #� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1&Received By January 31 0 July 1 &Rec ived By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> /6107 <br /> eceived by k Dat Receipt No. Permit No. IsdUancd 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 /> i � f <br />