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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendabie) PUMP&WELL „ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY <br /> Application is herVy made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San JoLin cal Health District. <br /> Exact Site Address Lam/ 1E AlazAX 1z A. City/Town <br /> � � .0 <br /> Owner's Name Gia. o Phone l,?/ -013 Z3 <br /> Address P0 f3o 7YIY City kl .r QA <br /> Contractor's Name n License#.SZ3l/Y Business Phone �'y�' 2�'I b d } <br /> Contractor's Address ! Emergency Phone <br /> Is Certificate of Workman's CompensationIn urance on File With SJ LH D? Yes X. No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /00 -,. Sewer Lines Pit Privy <br /> Sewage Disposal Field �6,1 f E Cesspool/Seepage Pit Other <br /> Property Line/0 Private Domestic Well •sa`-� Public Domestic Well <br /> INTENDED USE TYPE OF WELL 2 � <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 9.44 C c e tem <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout e r,. ,r <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: OL <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ t <br /> PUMP REPAIR: ❑ State Work Done - CA <br /> DESTRUCTION OF WELL: Well 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 /> 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 ersons subject to workman's compensation laws of California." <br /> I �11Gro Ainsp t' prior to grouting and a final inspection. <br /> r <br /> Signed X Title: Aq Q Date: Y' d <br /> (Draw Plot Plan on Reverse/Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � S` 10` <br /> Application Accepted By Date 7� <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By W1 Date S Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �% f 4 z <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issluance lbate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />