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Applications will Be Pro`cessad ften Submitted Properly Completed.Be Sure To Sign ThL.Application. ; <br /> FOFi OFFICE USE: ) �� APPLICATION - <br /> 1 ���` (For Nun-Transferable,Ravocable,SuspendaNe) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELLLd <br /> 1 <br /> (COMPLETE IN TRIPLICATE),—, 4 d-� L:a�� QUALIYY 2r�M� ` <br /> Application isherebyrnadetothe n oaquin Local Health District for a permit to construct and/or ins'za I I the work herein described-Thisapplication iss 1 <br /> made in compliance with San Jo9quin Gouniy Ordinance No- 1862 and Oe rulesand re iss of the Sari Joaquin Local Health District- l <br /> Exact Site Address a W l lit ily;Town <br /> Owner's Name M : 1 t, � �P hone <br /> Address 4D City <br /> ^+car s-P-Q. <br /> Contractor's Name __ License it -,eft?�'�siness Phone '�`�L_.7&2, <br /> Contractor's Address 4_!e Emergency Phone <br /> Is Certificate of Workman's Campartsationinsurautce on File Wit SJLHI]? Yes _ No <br /> z <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN 0 RECONDITION❑ DESTRUCTION❑ .4 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ 07HER ❑ PUMP INSTALLATION 0 PUMP REPAIRS Q ' <br /> REPLACEMENT❑ o <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _ fh <br /> Sewage Disposal Field Ce <br /> 9 P sspoollSeepage Pit Other <br /> Property Line Private Domestic well _ Public Domestic Well <br /> — _ I <br /> INTENDED USE - TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTICIPRIVATE ❑ DRILLED Dia. of Well Casing - <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information - -- <br /> ❑ GEOPHYSICAL Surface Seal Installed By: � N <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT- ❑ State Work Done <br /> PUMP REPAIR: State Work Done (6 <br /> DESTRUCTION OF WELL: Wall 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 /> Contraclors hiring or sub-contracting signature ca rtifies the following:"I certify that in the performance of trio work forwhich this <br /> permit is issued, I shall employ persons subject toyworkman's compensation laws of California." <br /> 1 ill Call for a Grout Ins on rE routing4ada final intpection, <br /> signed Title- rl _ date: <br /> {DrawPlan on Reverse Side[ JF <br /> F R DE RTMENT SE ONLY <br /> PRASE I <br /> Appf is orlon Accepted By XA,- _ „Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P III Final spection <br /> Inspection Sy— _ Date /�- Inspeetion By/'' date <br /> IF <br /> FOe 16 Due' ❑ ANNUALLY ❑ PER UNIT E3 MR SITE EACF ❑ January 1 b gece•ved ay January 31 ❑ July 1 G Rer*1vQC ay Jury 31 <br /> REU IT <br /> BILLING PEMITTANCE <br /> t3A5E EXPLANATIONNTE DArE REMITTED AMOUNT DUE CHECKED <br /> • AMOUNT <br /> FEE r <br /> LESS — <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> HsceivW by Data Rece,pt No Permit No, Imoarme Dela 11Ra1red Dal,vars-o -- <br /> APPUCAMT--119YUMAL.L CQPM TO; ENWAC)NMEHTAL HEALTH PEnM1riseRVICES ti01 E HA2ERTON AVE.,".Bps 2M STOCKTON,C ;7p <br />