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p)Ications Will Be Processed Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: S EP jz APPLICATION ` .y <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> SAI4 JOAQUIN LOVIUMONMENTAL HEALTH PERMIT- <br /> (COMPLETE IN TRIPLICAT�EALTH DISTRICT WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit toconstruct and/or install the work herein described.This application is <br /> made in compliancewithSan Joaq I County Ordnance No. 1862 and the rules and regulations of the Saff��Joaquin Local Health District. ' <br /> Exact Site Address�15 12. aMy I I e— _ City/Town l�Le.YneniS <br /> Owner's NameXR6 YJ dhM Phone r1 59— 3135 <br /> Address .6' City_ M e,hAs r Contractor's Name License#3mo i^t-® [3smess Ph ne tO2 —1 42 4 <br /> �� iui <br /> Contractor's Address Emergency Poe "`1'102.— ' ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ �^ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public DomesticiWell <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. iJ <br /> PUMP REPLACEMENT: State Work Don <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> � <br /> 1 will call for a Grout Inspection p or to gr Ing and a final inspection. <br /> Signed X / t��, 11_r Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By��1 �— �/` — �L Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phasq I F 1 Inspection <br /> Inspection By Date Inspection By ate C <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> a� <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> zs <br /> Received by Dale Receipt No. Permit No. Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />