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„ J� Applications Will Be Processed When Submitted Properly Completed. n7plication. <br /> F, ]R OFl i�E-i1SE: �APPLICAT as ` <br /> L . <br /> (Far Non-Transferable;Rev o 3ptfidable) <br /> ENVIRONMENTAL HE p� 4 �g-�g PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY � <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct dyiiJgQ vtiT�efiiF �reindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and rc I stiff"tfj}�[A��uin Local Health District. <br /> Exact Site Address 744 s'Z Lam. l�G Ti L �J9�.t1 e s21 �"City/Town C-CIO/ <br /> Owner's Name .99 �tl �_ f2 l Cfir Phone <br /> Address 1 g ��K !TL �✓l�h1 G.s1 City C- 0,0/ <br /> Contractor's Name License#38/Q/Z Business Phone <br /> Contractor's Address t1 �rr �% Emergency Phone -_.>�.Cpr=� 11 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes "� No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONN❑� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ ) <br /> REPLACEMENT❑ r <br /> r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines t it Privy N <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 Well Excavation to <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 F <br /> ❑ DISPOSAL ❑ OTHER Other Information I <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 5`,og_,. <br /> Type of Pump �Z g—_ a.-.¢j e H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done h ; <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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:'1-certify that in the performance of the work for which this permit y, i <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 call for a Grout Inspection for to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on se ) l <br /> t � <br /> F05 DEPART NT USE P.NBY flX 20 <br /> PHASE I L d Ornia 95240 tl <br /> Application1Accepted By Date <br /> Additional Comments: i <br /> Phase II Grout Inspection ha a III Final Inspection <br /> �_ ,-- 75 <br /> Inspection By Date Inspection By r' I� to <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT -❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> t y REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION =AMOUNT DUE CHECKED <br /> ,1 DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 4 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O X56 4_02_%Z2I <br /> Received by -Dat4 Receipt No. Permit No. . I suan a Datd Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAXELTON AVE.,.P.O.Box 2009 STOCKTON,CA 95201 -� <br />