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WW aQrls° iti W*d&sied*Aer-Submitted Properly Completed. Be Sure To Sign The Application. _ <br /> FOR OFFICE USE: ALL y� LIJ APPLICATION <br /> Non-Transferable, Revocable, Suspefidable) PUMP&WELL ' <br /> EtiltiRONMENTAL HEALTH PERMIT •F <br /> J0„QVLre;a WATER QUALITY <br /> {COMPLETE IN TRIPLICATj ] � Z� T <br /> Application is hereby made to the San JoaquinLocalthDistrictforapermittoconstructand/or install the work.herein described.This application is <br /> made in compliance Wh San Joaquin Co my Ordin ce No. 1862 and the rules and r gulations of theSan Joa u�n Local Hea h District. <br /> Exact Site Address City/Towrx� (_✓ &11�1. <br /> Owner's Name Phone 83,67-" C. V06 <br /> Address19-YtOl <br /> City <br /> Contractor's Name �.1 ,. cense# '[ g��'/�Business Phone L:�7�� <br /> Contractor's Address y Emergency Phone r, <br /> Is Certificate of Workman's Compensation Insurance on t=ile ith SJLHD? Yes_�_ -_ No <br /> TYPE OF WORK (CHECK): " NEW WELL =-DEEPEN ❑" RECONDITION❑- - - DESTRUCTION❑- t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ , PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ V' <br /> DISTANCE TO NEAREST: Septic Tank..' Sewer Lines Pit Privy Y Sewage Disposal Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well�, !Public Domestic Well <br /> INTENDED USE r TYPE OF WELL j fy y <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ^� . <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing F��/�6�+✓ <br /> ❑ DOMESTIC/PUBLIC ��❑{{DRIVEN Gauge of Casing � � N <br /> ❑ IRRIGATION }.GRAVEL PACK Depth of Grout Seal. <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout _ <br /> 0 DISPOSAL ❑ OTHER Other Information ,6 — ! <br /> ❑ GEOPHYSICAL. Surface Seal Installed By: /� + <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth . <br /> r f <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work`wiilbe-done in'accordance w#r,5an 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 thework`for which this permit ,. <br /> f is issued, I shall not employ any person in such manner as to becomejslibject to workman's compensation laws of California." <br /> Contractor's hiring pr sub-contracting signature certifies the following:"I ce`rtify.that in'theperformance of the wo"rk forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensationr"laws of Califo?nia. <br /> -I will all for a"Grout Ins tion prior to grouting and a final insp on. . w1 ' <br /> of <br /> Signed X Title. _... Date: 1 <br /> (Draw Pl Plan on Revgrse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - i07 <br /> ' <br /> Application Accepted B Date - 6S <br /> Additional Comments: ` <br /> Phase argol Inspection 7 1h -3 Phase 111 Final Inspection <br /> Inspection By Datey`< Inspection By Date <br /> Fee Is Due: 11-ANNUALLY ❑ PER UNIT ❑ PER SITE +❑ EACH,­ - ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i - - - REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - - AMOUNT <br /> FEE ' <br /> _ I <br /> LESS _t A I <br /> PRORATION <br /> PLUS <br /> I <br /> PENALTY <br /> OTHER % ° <br /> N. <br /> 't 1 <br /> w.:�_. <br /> OTHER w.s. <br /> 4 <br /> Received by _ Da Receipt No.. ' " 1.1_ Permit No. - - Issuance Dae Mailed Delivered <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> I <br />