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ApplicationsWill BeProcessedWhenSubmitted ProperlyCompleted Be SureTo Sign TheApplicationa <br /> FOR OFFICE USE: 70 APPLICATION - <br /> �J /'0 (For Non-Transferable, Revocable, Suspendable) <br /> i 7 <br /> el PUMP&WELL <br /> WATER f <br /> /V v <br /> ENVIRONMENTAL HEALTH PERMIT �/ <br /> o <br /> (COMPLETE IN TRIPLICATE) Q <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct a d/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 " ty/Town _j59&9lf CAM? X43 <br /> Owner's Name , (!l - - e <br /> Address _--- dcr .4.6 Citycu <br /> + <br /> Contractor's Name '�/y47" &44A & License#4Z, 5'2 Business Pho e <br /> Contractor's Address Emergency Phone F -- <br /> Is Certificate of Workman's Compensation nsurance on File With SJLHD? Yes_>_<_ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR01 f <br />,f REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank .2tV Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL pia. of Well Excavation // a <br /> �DOMESTIC/PRIVATE ❑ DRILLED Dia. of Wel€ Casing C41 <br /> ❑ DOMESTIC/PUBLIC ,❑ DRIVEN Gauge of Casing _RAC ACO ; <br /> ❑ IRRIGATION WF G AVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION Q ROTARY Type of Grout %EAn?3V,0W' <br /> ❑ DISPOSAL ❑ OTHER Other Information _ -y <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> y= <br /> PUMP INSTALLATION: Contractor <br /> �'-! Type of Pump H.P. <br /> PUMP REPLACEMENT: I�r// WW❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done �~ 0 <br /> DESTRUCTION OF WELL: V Well Diameter Approximate Depth L ; <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wWcallrroutpection prior to grouting and a f€ial-inspect€on. <br /> T <br /> i n Title: _ Date: <br /> Signed X �rn�1 --var <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY a <br /> PHASE I eiRl <br /> Application Accepted By Dates.? t i <br /> Additional Comments: <br /> SII <br /> Pha a 'Grout J _ pection Ph ise III Final Inspection <br /> Inspection By at Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PERNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ y <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT ,. I <br /> FEES <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> h <br /> Received by Date Receipt No. Permit No. ssuance ate Mailed Delivered <br /> x. _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />