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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION �= L7, <br /> (For Non-Transferable, Revocable,Suspendable) -J <br /> PUMP&WEVU—- <br /> ENVIRONMENTAL HEALTH PERMIT -p <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 the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /94QO L-/400 -r9 T- -P-P City/Town ✓r � ��'� <br /> Owner's Name _-' /� C'-E Phone�.W`59 4 aa_& 3 Fl? <br /> Address /9/6L U TIMI�T �D-r CJ-�a�C-�3� City 5727! —_ WY 9 5 o-Ze <br /> Contractor's Name li /*_1iW t/I ezz �.6/44&&Z__ License#3370,'ZBusiness Phone ,_15' -3-?5 <br /> Contractor's Address To 6e(''3 - f ��it/JAA/ 5 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance.on File With SJLHD? Yes_ l No f <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> r <br /> DISTANCE TO NEAREST: Septic Tank /3 - Sewer Lines 3� Pit Privy <br /> Sewage Disposal Field /DX /_ Cesspool/Seepage Pit — Other - <br /> Property Line ­010r Private Domestic Well /de 70__Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> n <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /p - <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 9er C-�,R,6'eN7 GeVee <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor_ S+J, �/�4/ - <br /> Type of Pump / H.P. 3 <br /> PUMP REPLACEMENT: ❑ State Work Doneev <br /> PUMP REPAIR: ❑J 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. _ li <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will v4II for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X _ Title: Date: - <br /> I (Draw Plot Plan on Reverse Side) <br /> '`FOR DEPARTMENT USE ONLYZa-r -�� R-c_e/�� <br /> PHASEI _ <br /> Application Accepted By Date <br /> Additional Comments: _ <br /> Phase II Grout Inspectio N` Phase Il Final nspection <br /> Inspection By a i�-L � <br /> - 4 Inspection By�a�-�►,.�- ��a� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jantuary.l &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED 5 <br /> 1 DATE HATE <br /> REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> 1 <br /> OTHER <br /> M k <br /> OTHER <br /> Received 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.Boa 2009 STOCKTON,CA 95201 <br />