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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-Transierable, 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 District for a 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 tbe rules and regula Ions of the San Joaquin Local Health District. t <br /> Exact Site Address EE/" r,� ]G r-��F � f Z��["_ C City/Town V Mi -c x <br /> r,r 2 6?/- <br /> Owner's Name AT- 010dPi9 �6 �[�!✓C__���1 �..cJiT� Phone ��" <br /> Address /IqAo City <br /> Contractor's Name License#�W3'1a�5Business Phone LS'0 40/"-fit-73-9 C> <br /> Contractor's Address SCc_e7., 0,-,7S Emergency Phone ) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No fl <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONAZ/ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 _3 6r <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 5r-aOTARY Type of Grout G k <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 4 GEOPHYSICAL Surface Seal Installed By: rb�r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done f <br /> PUMP REPAIR: ❑ State Work Done _ <br /> t <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 wi 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 forwhich 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill all to Grout lnsDecftn prior to grouting and a final inspection. <br /> Signed X Title:./&/ � � �� Date: /Xlbe 90 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ ) <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection I Final Inspection <br /> Inspection By Date Inspection B Date ; <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE R�r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �� ay C)-3S7 11 a w <br /> Received by Date Receipt No. Permit No. IssuanceDate Mailed Delivered <br /> :� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21109 STOCKTQN.CA 95201 <br />