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ApplicationsWillBeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> ;. FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> J <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.T is application is <br /> made in compliance wit an aquin Co t Ordin c 1862 a les and regulations of the Sa n <br /> 6 d :!M istrict. <br /> Exact Site Address C AlCity/Town <br /> Owner's Name � - �L V 5- JV S`f E 0!! O Phone A5 ^— 6 <br /> o <br /> Address I. City 25 dff_K_lz Al <br /> Contractor's Name C.C, e# Business Phone <br /> Contractor's Address 0 G ency Phone <br /> Is Certificate of Workman's Compensation Ins rance on File ith SJLHD? Yes� No <br /> TYPE OF WORK (CHECK): NEW WEDEEPENDEEPEN ❑ RECONDITION ElDESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION 13PUMP REPAIR <br /> REPLACEMENT❑ <br /> ' DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field_� cesspool/Seepage Pit O h r <br /> E 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 /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout /�/7` <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump I ( H.P. . <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter I Approximate Depth <br /> Describe Material and Procedure *01 <br /> 1 1 1 i _ <br /> I hereby certify that Ihave 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 certlfiesrthe following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any tperson-in such rnannor as to become subject to workman's compensation laws of California." <br /> Contractor's hiring orsub-contracting signature%ertities ih -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."I f <br /> I will c ora out In ection r' r to grouting and a final inspe. tlio s <br /> Signed X Title: _ Date: <br /> l <br /> (Draw Plot Plan on Reyerse,Side) I y r <br /> FOR DEPARTMENT USE ONLY �. <br /> PHASE I <br /> (` `a ',tr . { I _ e V <br /> Application Accepted By �^ � � _ r�.� Date x <br /> Additional Comments: �� ""t =' s` - Y 9 I <br /> Phase II Grout Inspection Phas III Final Inspection <br /> i Inspection By Date___Lt! Inspection By D to r <br /> Fee Is Due: ❑'ANNUAL✓_Y• ❑ PER UNIT ❑-PER//R-S4rE -r-'❑ EACH ©-January 1 &Received By Januar 3i <br /> - _ 10 <br /> y -❑ July 1 &Received By July 31 0 <br /> KR, REMIT—BASE::- =EXPLANATIONLLING dREMITTANC6) $ pATE PATE REMITTED " AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT <br /> C <br /> LESS <br /> PRORATION <br />' PLUS <br /> PENALTY _ <br /> OTHER -°rl �. s } "� '� �,• <br /> OTHER <br /> Received by - Date :, Receipt No. Permit No `3 Iss�.uance ate Mailed Delivered- <br /> • <br /> 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COMES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />