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ApplicationsWill Be Processed When Submitted PropeRAy Completed. Be Sure To Sign The Application. " ^ <br /> FOR OFFICE US.U:.- . APPUCATION <br /> f f_ 6 yyLr (For Non-Transferable, Revocable, Suspendable) <br /> f F ENVIRONMENTAL HEALTH PERMIT PUMA&WELL <br /> - (COMPLETE IN TRIPLICATE "" �"' ""` " <br /> rS�sb_:_ _- cfE .9-w TT R_QuALITr <br /> Application is hereby made to the San Joaquin LocalHealthDistrictforapermittoconstructandlorinstailiheworkhereindescribed.7hisappficationis <br /> made in compliance with San Joaq in County Ordinance No. 1862 an the rulesan regulations of the San Joaquin Local Health District. <br /> Exact Site Address � P�/1611 �ii <br /> 14g�E,�,�'4 4--/J — City/Yawn <br /> Owner's Name G a OC C.w 10 .0 <br /> Phone <br /> Address <br /> - City <br /> Contractor's Name License# Or-4-71 Business Phone G —'' <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No 4r <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONPUMP REPAIR C> <br /> REPLACEMENT El1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other V � <br /> Property LinePrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL. ❑ CABLE TOOL ` <br /> Dia. of Well Excavation <br /> ❑ DOMESTIC/ IVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ <br /> DOMES, /PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal vl <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Install d By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �+.t Y' H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 19 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. o� <br /> Homeowner or licensed agent's signature certifies the following:".I certify that in the performance of the work forwhich 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 'li call for a Grout Inspection''. for o I g•and a final inspection.W <br /> Signed itle k �� Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By d Date <br /> Additional Comments: ■ <br /> k <br /> 4 <br /> Phase II Grout inspection Ph III Final Inspection ' <br /> Inspection By. Date Inspection By Date p <br /> Fee Is Due: ❑ ANNUALLY # <br /> ❑ PER UNIT PER SITE EACH ❑.January 1 &ReceiveRy-January 31 ❑ July 1 8 Received By July 31 <br /> t <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> _ HATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> . l <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance ate - Mailed- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH�PERMITISERVICES <br /> ., f_ s 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTpN,CA.15201 ;`+ <br />