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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> Ft?,ft'OFFIO,E USE: / APPLICATION <br /> Ca 10*14.je (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) (NATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaq in Lo I Health District. <br /> Exact Site Address S� j City/Town 74 . n <br /> Owner's Name r��� JXZs i,�lz; _ Phone <br /> If <br /> Address l g `� ��-' City II? <br /> Contractor's Name "�tl License#&3-71,- —Business Phone 5,!�6 1-9 <br /> Contractor's Address at Emergency Phone A <br /> Is Certificate of Workman's Compensation Insurance on File With PLI-ID? Yes ' No <br /> TYPE OF WORK (CHECK); NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 5ff 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 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 /> 0 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: A <br /> PUMP INSTALLATION: Contractor CSISAJo— 411,111 <br /> Type of Pump H.P. ® 0 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 0 State Work Done <br /> -161111 Approximate Depth <br /> Describe M terial and Frocedure &J VA/ <br /> r i!l 6e age) <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 /> 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." <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 wil call for a Grout Inspection prio o ro g nd a f• al inspection. <br /> Signed XJ. ew« e: Date: <br /> (Draw Piot n on Reverse Side) <br /> _ e <br /> PHASE [ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout inspection ha Fi I Inspection <br /> Inspection By pate In pection By �,{/�te <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O <br /> q2 b 3 3 6 <br /> Received by Date Receipt No. Permit No Issu nce Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 , <br />