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Applications Will-Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> c =FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> y ENVIRONMENTAL HEALTH PERMIT <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 wSan Joaquin County Ordinance No. 18,62 andel the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address A717 F 1 zBB� .�r0 City/Town <br /> I Owner's Name _AL L �Q <br /> _ / Phone 1 <br /> Address —�- 2 'Cr S/ City C.off—ri <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION `L PUMP REPAIR❑ <br /> REPLACEMENT❑ E l <br /> DISTANCE T'0 N A`REST: Septic Tank Isewei Lines Pit Privy; iy <br /> Sewage Disposal Field_�4� Cesspool/Seepage Pit Other ff <br /> �Ifj+?� I Property Line Private Domestic Well ___!!,Public Domestic Well <br /> INTENDED USE �JS/ TYPE OF WELL <br /> ❑ INDUSTRIAL ! ❑ CABLE TOOL Dia. of Well Excavation <br /> X DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing-^m t <br /> ❑`DOMESTIC/PUBLIC L ❑ DRIVEN Gauge of Cas ni gT- <br /> ❑IRRIGATION I ❑ GRAVEL PACK �rDepth of Grout Seta ` <br /> ` ❑ICATHODIC PROTECTION t 13 ROTARY Type of Grout t <br /> ❑DISPOSAL ❑ OTHER Other Information <br /> ❑GEOPHYSICAL { ' Surface Seal installed By: <br /> PUMP INSTALLATION: " Contractor ,.� I <br /> f i Type of Pump H.P. t <br /> 41 <br /> PUMP REPLACEMENT: El State Work pone # <br /> G PUMP REPAIR_ „ P,State,Work.Done <br /> DESTRUCTION OF WELL: Well Diameter IJ f r+"'!t �—� � Approximate Depth <br /> Describe Material and Procedure <br /> - t <br /> s I hereby certify that`I have pared 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.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 /> € 1'i Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> V,� y permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> I M <br /> i (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �n_ �l o-�� 'D <br /> Application Accepted By �( �ti 11 �"'�0�. Date <br /> I k Additional Comments: — — <br /> Phase II Grout Inspection Ph If Final spection / <br /> -1, 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 July 31 <br /> Z�ir <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS f <br /> PENALTY <br /> OTHER <br /> k <br /> OTHER <br /> # i 125 rA5.o 5�3� Z�13 � So <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.Boz 2009 STOCKTON,CA 95201 <br />