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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,FOR-OFrICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin COU nyg <br /> t /Ordinance No.1862 and the rules and.re ulations of the Sa quin Lo al Health District. <br /> Exact Site Address City/Town �� � <br /> Owner's Name CR�f�S +� Phone <br /> Address i� 1..� Q ���r- City Gq <br /> Contractor's Name Lo�L P �*+ f License#I t 5 Busine s Phone JV <br /> (t1Z—s� <br /> Emergency Contractor's Address _Lb Z. gene�- Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes f� No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ p� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /J U� t Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 1 <br /> Property Line - Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL y�� �. <br /> 11INDUSTR11IAL CABLE TOOL Dia, of Well Excavation 7 <br /> ¢ rr } <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ` � W �9 g' - 2 L-V <br /> ❑rDR1VEf�- Gain a of Casln <br /> ❑ IRRIGATION 13 GRAVEL PACK, ,Depth of Grout Seal - n <br /> ❑ CATHO0DIC PROTECTION Y' ROTARY t` T9$S.@,Groutw <br /> ❑ DISPOSAL ❑ OTHER -- tfier.lnrormat on <br /> _. <br /> ❑ GEOPHYSICAL `"`^ as Surface�Seal Installed By: <br /> PUMP INSTALLATION: _ Contractor <br /> •• <br /> H.P.�, <br /> PUMP REPLACEMENT ypeP4 �R <br /> z�.. ❑,;,5tate,W.ork Done <br /> PUMP REPAIR: 0 State Work Done ; <br /> DESTRUCTION OF WEEL: 4V7,-Il Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ate. } •J ^ Y I <br /> I hereby certify that I have preps ,Jbis application and that the work will be done in accordance with San Joaquin County <br /> ordinances state laws, and rules iih_rrggulations df-fhe San Joaquin Local Health District. r I <br /> Home ownef or licensed agent's signature certilies the following:"1 certify that in the performance of the work for which this permit <br /> i issued, I shall not employ any person-ip such manner as to'become supjbct to workman's compensation laws of California." <br /> iractor'shiring or sub-contractingigneture certilies the following:"I certif:that in the performance of the work for which this <br /> e mit is issue , I shall a ploy ersons subject to workman's compensation laws of California." <br /> I call for atprout, a tion rior-4o grouting-and-a final-inspection._, <br /> Signed X Title: ` U''' Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> z <br /> FOR DEPARTMENT USE ONLY / 4XA O'q <br /> PHASE t 10 <br /> Application Accepted y Date4`1 <br /> Additional Comment : <br /> 4 hasL11 Grout Inspection Phase III Final Inspection <br /> Inspection By r Date�o- 3a'�� Inspection By �/-� Date <br /> I <br /> Fee Is Due: [1 ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH El January 1 8 Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> gBASE EXPLANATION BILLING REMITTANCE $ AMOUNTOUE CHECKED <br /> 1 F DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY "; 4 r` �%ev <br /> L <br /> 3 sc 6s� �t <br /> OTHER <br /> OTHER x',* <br /> i <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: �ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bol 2D09 STOCKTON,CA 95201 <br /> 111 i . <br />