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Applications Will Be Processed WhenSubmittedProperlyCompleted. 6e iosign ineappucaaor <br /> FOR OFFICE USE' <br /> JU <br /> (For Non-Transierable, Revocable, Suspendable) <br /> PUMP &.WELL <br /> ENVIRONMENTAL HEALTH P T SAN JCI OU'lIN LOCA s /D <br /> �Z , , <br /> (COMPLETE IN TRIPLICATE) 3U Losf WATER QUALIT HEALTH DISTRfC .-> <br /> jv •� <br /> Application is hereby madetoth anoaquinLocal Health District-f-orapermi construct and/or install the work hereirrdescrlbed.Thisapplicationis� <br /> made in compliance with San Joaquin County Ordinance Nu. 1862und t rules and r gulatio �Of tai ,n Joaquin Local Health District. <br /> Exact Site Address lr �f F �1 -I,�f d' <br /> It wn d <br /> Owner's Name /T?,0o 7A 0-0 Phone 3C,'9' <br /> Address ��_ .�-5�'- ®��. ?;R-a � �y °� City <br /> Contractor's Name- :;Le-G c 'R 5 License#/8a Business Phone <br /> Contractor's Adad L Emergency Phone 5 <br /> Is Certificate of Workman's Compensation I,n�sura cc on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL Cl-- DEEPEN ❑ RECONDITION❑ DESTRVCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLiINION ®--' PUMP REPAIR❑ <br /> REPLACEMENT❑ G <br /> DISTANCE TO NEAREST: Septic TankSewer Lines �� Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line4–<=)—,!N Private Domestic Well e---- Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 2 <br /> �OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5 C] <br /> ❑ CATHODIC PROTECTION P-MOTARY Type of Grout /. <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: f <br /> PUMP INSTALLATION: Contracto <Q r-% B S <br /> Type of Pump , �+ H.P. D <br /> PUMP REPLACEMENT: ❑ State Work Done <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:"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 call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed Title: � ,� Date: <br /> (Draw Plot Pian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I d Date L �U <br /> Application Accepted By <br /> �V <br /> Additional Comments: j/ <br /> Ph ro ffspection P se II Tuly <br /> ctionInspection By Date �� �v _ Inspection By ate gFee IS Due: ❑ ANNUALLY ❑ PERU IT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> RASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> w, <br /> ^r'.eived 6y Date Receipt No. Permit No. Issuance Dafe Mailed Delivered <br /> T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH pEhMiT1SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />