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Applications Will Be Processed When Submitted ProperlyComplet e fir o ggThlqA�icM <br /> FOR 0 IVICE'USE: APPLICATION JJ�� <br /> (For Non-Transferable, Revocable, Sus ble)NOV2 5 1900 <br /> tv V JO PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN ,JOP-111,11N LOCAL <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or ipfMfffj DrIDWY&Rltalcribed.This application is <br /> made in compliance with San Joaquin County Ordinapce No. 18 <br /> _�6A and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address to ►Oe- . City/Town <br /> EA.Cc� <br /> Owner's Name l�l'��I _O.S7-,Q Phone 96, -29q-3 _ <br /> Address anL� city��s f iJLf1/S/ <br /> Contractor's Name License#,:2770/0 Business Phone C5-38 12Ze <br /> 90 <br /> Contractor's Address c2Ef'1.F Emergency Phone Ccro7:?a v-z�7._.. <br /> , <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes eVlk—� No I <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® d <br /> REPLACEMENT❑ N <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field' Cesspool/Seepage Pit Other <br /> 1 <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 r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout d; <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 u ! r <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 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 /> I will for Grout I ctio prior to grouting and a final inspec' <br /> Signed X Title: /ern Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase li Grout Inspection nal Inspection <br /> Inspection By M In Date Inspection ZvledBy <br /> Date <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & January 31 ❑ July 1 &Received By July 31 <br /> REMiT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> M* I I I;�51&6 5�+7 5 Ok 5,5�6 ll/2g Imoo <br /> Received by Date Receipt No. Permit No. Issuance 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 />