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y <br /> t pplications Will tae Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> R OFAPPLICATION <br /> i (Far Non-Transferable, Revocable,Suspendable) � <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL Co <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install thew ork herein described.This application is " <br /> made in compliance with San Joaquin Cou Ordinance No. 1862 and a rules and re ulat'ons of the San Joa ui L alth pistrict. <br /> Exact Site Address s �. SL+e IO 7� �• a :, City/Towne Y`J <br /> Owner's Name G }"`F-4ES Phone 14 Z <br /> r <br /> Address City <br /> Contractor's Name V License#1 _ Business Phone r <br /> Contractor's Address Emergency Phone' 004 ' <br /> Is Certificate of Workman's Compensation Insurance on File SJLHD? Yes o I <br /> TYPE OF WORK (CHECK): NEW WELL 13DEEPE RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ -+ /601 *0 0,Vt #ft6S7— .7 ! mcru0- Q� ; <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 Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIALCABLE 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 iV <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. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth , <br /> Describe Material and Procedure w e <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 ofthework 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,thatan the performanceof the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." J <br /> I will cal for at ectio r to grouting and a final inspectio <br /> Signed X A Title: —V Dat <br /> (Draw Plot Plan on Reverse Side) <br /> FORD PARTMENT USE ONLY <br /> PHASEI p <br /> Application Accepted By _Vy Date <br /> 'y <br /> Additional Comments: — . <br /> Phase II Grout In pectto hese al inspection"" — :r <br /> }�C� J F <br /> Inspection By CJaie ! '_ 'InspectioD,By Date <br /> .O ' <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT y3 PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> [ <br /> BASF EXPLANATION BILLING REMITTANCE $ REMIT _ r <br /> DATE DATE REMITTED AMOUNT DUE CHECKED t <br /> AMOUNT <br /> FEE <br /> Q/t r <br /> LESS _ v. <br /> PRORATION <br /> 'F <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ! <br /> r <br /> ' a3 W-1I �d <br /> Received by Date Receipt No, Permit No. Issu nee 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 />