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Applications Will Be Processed When Submitted Properly Como*). I06Me46ftnvrh6-App�i�$t�on, <br /> FOR 0FFiCE USE: APPLICATION IT➢JI 3 <br /> (For Non-Transferable, Revocable, Suspenda V 2 6 1979 <br /> �. PUMP&WELL <br /> Op ENVIRONMENTAL HEALTH PERMIT <br /> SAN JOAQUIN LOCAL � <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY � olS�RIGr <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and I I he46 wor eretndescribed.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 Ahiddress 07 411 Z-aht M City/Town <br /> Owner's Nalti�e �'7 I��C- Phone 1q- <br /> 1 <br /> - <br /> Address �M �f2`I L•'alvl City +` <br /> Contractor's Name �w f- co, License# Business Phone <br /> ,II: � r <br /> Contractor's Address Q �� Emergency Phone +: <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No ;_t <br /> TYPE OF WkORK (CHECK): NEWS WELL DEEPEN 11RECONDITION❑ ' DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMIENT❑ <br /> DISTANCE . NEAREST: Septiank ;L067 Sewer Lines �'t9� Pit Privy <br /> Sew." Disposal Reid 9-y i Cesspool/Seepage Pit Other <br /> Property Line_ Private Domestic Well '� Public Domestic Well <br /> INTENDED USE TYPE OF WELL f f <br /> ❑.INDUST4RIAL I ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMES IC/PRIVATE ❑ DRILLED Dia. of Well Casing ; <br /> ❑ DOMESk IC/PUBLIC ❑ DRIVEN Gauge of Casing 0 S # <br /> ❑ IRRIGATION RAVEL PACK Depth of Grout Seal s <br /> ❑ CATHODIC PROTECTION 3�ROTARY Type of Grout O n �i <br /> ❑ DISPOSAL /,h p��tO` <br /> ❑ OTHER Other Information _ cr I <br /> ❑ GEOPHI SICAL Surface Seal Installed By: Y <br /> PUMP INSTALLATION: Contractor ' <br /> !I! Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done It" <br /> PUMP REPAIR: I �❑ State Work Done <br /> DESTRUCTION OF WELL: I Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin County <br /> PP <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I'Home owner orlicensedpagent's signature certifies the following:"I certify that in the performance of the work for which this permit � <br /> I'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 isulb-contracting signature certifies the following:"I certify that in the performance of the work for which this i permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I <br /> illwill call for a Grout speclion prior to grouting and a final inspection. <br /> Signed X Title: � Date. <br /> II �p (Draw Plot Plan on Reverse Side) <br /> FO EPART NT USE ONLY <br /> PRASE I l� 9 <br />+ <br /> Application Accepted By— Date l G / <br /> kAdditional Comments: <br />{. ii Phasfl Grout Inspection Phase III Fina ectio , <br /> I Inspection By Date �" Inspection By �� Date` z � <br /> FeeI W C rm <br /> ls Due: ❑ ANNUALLY -I❑ PER UNIT PER SITE ❑ EACH January 1 &Received y January 3 Juiy 1 &Received By July 31 <br /> i REMIT <br /> �, <br /> BASE! EXPLANATION - BILLING REMITTANCE _$ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT «F <br /> 4 <br /> V. FEEjp. Il _ <br /> LES <br /> PROS E• �� <br /> RATION <br /> PLUS �r <br /> PENALTY tl <br /> d, �. _ <br /> OTHER �I <br /> .¢ <br /> OTAtER <br /> r <br /> Cpl p° ---i <br /> - <br /> Recyye�ived by Date ll} _ Receipt No. Permit No. ssuanc Date Mailed Delivered - <br /> MPPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 E.HAZELTON.AYE.,P.O.Box 2009 "STOCKTON,C <br />