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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 1�6'F�FIC u5E: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PYMPP&WELL <br /> ENVI!36NM�NTAL HEALTH PERMIT """ <br /> I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instals the work herein described.This application is r� <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health Dis rict. v <br /> Exact Site Address •�Oc-trSC' /�4. /E� � �� !<(�;r_ir-e-- 1- City/Town <br /> Owner's Name _fC ! G'i+�� I C�C'�»rcl-� Phone r' `2's <br /> Address i3o7 , I��] City ��'U ��. <br /> 00 <br /> Contractor's Name�s -..{' i� - C; License# Business Phone <br /> Contractor's Address Z_S 1`;71V,1-11e' — cr5'k' ,Emergency Phone r^ _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Ner✓ <br /> TYPE OF WORK (CHECK): NEW WELL FSI DEEPEN ❑ RECONDITION❑ DESTRUCTIO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 91 ' PUMP INSTALLATIO PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy — <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line I 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 �� t <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ��G1 f}Pi-WSt4L[CaCIP[lnitl� Surface's/ea! Installed By: -- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -- /V ZA H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done_ Oz <br /> PUMP REPAIR: State Work Done 7 <br /> DESTRUCTION OF WELL: Well Diameter A oximate Depth <br /> - Describe Material and Procedur .e .. _ 7� <br /> I hereby cer Ily that I have prepared this a plication and that the work will one in accordance with San Joa In 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 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." +1 <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Gro I. Inspec in prior to grouting and a final Inspection. <br /> �lr fid �% SS <br /> Signed X �1Title: �"�1r� Dale: <br /> �jI/ aL- �`�' (Draw Plot Plan on Reverse 9ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T <br /> Application Accepted By Date' <br /> Additional Comments: <br /> Phase If Grout Inspection F&I al inspection <br /> Inspection By Date Inspection B at, <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 &Received By July 31 <br /> 131LLING REMITTANCE REMIT <br /> $ <br /> SASE EXPLANATION DATE DATE REWTTE0 AMOUNT DUE CHECKED <br /> qi in _ AMOUNT__-� <br /> 1 <br /> FEE <br /> LESS <br /> PRORATION r <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No. Permit No. Issuance Date Mailed Delivered r <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />