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Applications Will-B'6 rocessed When Subrnil#e9* p ly Completed. Be Sure to—sign The Application. <br /> FOR OFFICE USE: fi m -. APPLICATION' - ` <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ---- PUMP&WELL <br /> - fi---"ENVIRONMENTAL_HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ` `� WATER QUALITY <br /> r <br /> Appl ication is hereby made to the Sar)`Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> w made in-compliance with San Joaquin County Ordinance No. 1862 ansa-thre rules and regulations of the San Joaquin{-Local ideal District. <br /> E Exact Site Address `� <br /> City/Town c� <br /> Owner's Name _ ?'✓ter f. r;;l.y -` +i" r lw._3 Phone <br /> p Address . 1 t ;ir City en<� , <br /> ._ <br /> Contractor's Name iZ4 6;ted a_�� License# 7 1 C_ Business Phone <br /> Contractor's Address _ �2 " G ir�t - e r'a 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 ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> r" <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ` <br /> ❑ INDUSTRIAL ❑ 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: {1y <br /> ' PUMP INSTALLATION: Contractor t '?1 / .1 . :;, i- ' <br /> ------------- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 0 State Work Done 'rt -s`. l .:. -(­Tto,.4! sis .lrf , <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof thework 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 /> r <br /> I will call for a Grout Inspection prlo"r;to gro ng and a�final inspection. <br /> Signed X T�'.ry ' x . a - Title- r Date: _ l <br /> t� (Draw Pin4f6lan on Reverse Side) <br /> FPA DEPARTMENT USE ONLY I <br /> PHASE I j J` <br /> Application Accepted Byp e. <br /> Additional Comments <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee 1s Due: ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILL3NG REMITTANCE $ AMOUNT DUE CHECKED { <br /> • RATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 12 Z <br /> PLUS a <br /> PENALTY <br /> OTHER # <br /> OTHER q r Iq <br /> 77 <br /> Received by 7 Da `i fleceipt No Permit No. Iss ante ate Matted Delivered <br /> APPLICANT. RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.'HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />