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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFUZ-E USE: APPLICATION <br /> (For Non-Transferable, Revocable, 5uspendable) � <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 thework herein described.This application is ! <br /> made in compliance with San Joaquin County Ordinance No. 1852 and the rules and regulations of the San aquin Local Health District. } <br /> Exact Site Address�-_12 _!i-41 fAl 0 r &,ejqq City/TownC14M 917 // 1 <br /> Owner's Name. Q Phone "�� �/ 7� 1l���,l, d <br /> Address s* 3 { ' City�SU�tJ/l.ril ffirl� 9 f 0�6<__ <br /> Contractor's Name C/N/rof.V/1_4;9� t_icense#26y Business P 6 !9� 4 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I !+ <br /> WELL CHLORINATION ❑ : WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT�r <br /> � f <br /> DISTANCE TO NEAREST: Septic Tanks '7' Sewer trines Pit Privy <br /> Sewage Disposal Field 56 /1:::. Cesspool/Seepage Pit Other <br /> Property LineA;A 0' Private Domestic Well Public Domestic Well r <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> D MESTIC/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 4 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor VAI, ye-e?('&Z r�+�- e-p 1-4 /•"-Q7 <br /> Type of Pump �1 H.P. <br /> PUMP REPLACEMENT: E1'9tateWork Done )Fi , "77� <br /> PUMP REPAIR: ❑:State Work Done h <br /> DESTRUCTION OF WELL: WellDiameter _ Approximate Depth t <br /> Describe Material and Procedure <br /> 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 /> Homeowner 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:"l 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 /> 1 will call for a Grout Inspect nor to grouting nd a final inspecti q / <br /> Signed X Title: Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTM NT USE ONLY <br /> PHASE 1 <br /> A�Lfir <br /> Application Accepted ByDate l7 r <br /> Additional Comments: --: <br /> Phase II Grout Inspection Pha a III Final Inspection <br /> Inspection By _ { Date Inspection By Date a <br /> Fee Is Due: 11 ANNUALLY <br /> El UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ J"`�Received By July 31 <br /> d <br /> REMIT t <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEElfS �J A� <br /> 7 t <br /> LESS ' <br /> PRORATION <br /> PLUS *{ i <br /> PENALTY i <br /> OTHER f j . <br /> OTHER ?esF f1. <br /> Received by Date Receipt No. Permit No. , —Issuance Date Mailed Delivered : <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20139 STOCKTON,CA-952 <br />