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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,-Revocable,'Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE Wil.�' �..r p -QUALITY /g3- 330 3s <br /> ( ) �, So C. S.,rte-rJ7�l t` "� . r <br /> Application is hereby made to the San Joaquin Local Health Distri fora permit to construct and/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 AddressCity/Town l S�"aG<To <br /> Owners Name � L Ll� �.L.tAt'D�. .1t.1'r __-. Phone '[9 tr <br /> Address 7.V A��! R&O� . I t City_- S'Taej �(] <br /> CL-W od <br /> Contractor's Name wou.4 ezu tf License# 3 <br /> . {� Business Phone <br /> Contractor's Address LO N6 Emergency Phone 0 �� I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No a, <br /> TYPE OF WORK (CHECK): NEW WELL❑ ' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®'PUMP REPAIR❑ <br /> REPLACEMENT❑ t <br /> DISTANCE TO NEAREST: Septic Tank too r Sewer Lines . IV 0 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 /> ❑�STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑, EL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION [J ROTARY Type of Grout <br /> ❑ DISPOSAL - ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL t Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor OU31ag-ill 14*IM-L-" lam <br /> Type of Pump 5�'Is1�EA11'��.L _ H.P. I L <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 /> t <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 Jaws, 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 performance of the work for which this permit <br /> is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Con actor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this r <br /> per t is issued, I shall emplo persons subject to workman's compensation laws of California." <br /> I w all fora G t Ins n pri to grouting and a final in ction. Q . <br /> Signed X, Title: Date: *11 v <br /> (Draw Plot Plan on R erse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I t f� s s� y�1 <br /> Application Accepted By � � ,�`_ _- --• -- Date 1 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By :. �o Date Inspection By- - pate <br /> •� y 4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT "❑- PER SITE ❑ EACH -❑ January 1 &Received By January 31 ' ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE. $ REMIT <br /> - BASE EXPLANATION DATE DATE REMITTED - AMOUNT DUE CHECKED <br /> AMOUNT <br /> r FEE v <br /> LESS " <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER + <br /> s. <br /> OTHER <br /> ` Received by Date Receipt No..--. 'Permit No. _ - I suanc Dat ,.t Mailed Delivered - <br /> APPLICANT—RETURN`ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />