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Applications Will Be Processed When Submitted;PropeFLy-----.r- <br /> FOR OFFICE USE: APPLICATION = . <br /> (For Non-Transierable, Revocable, Suspendable) <br /> PUMP&WELL M <br /> n ENVIRONMENTAL HEALTH PERMIT r <br /> (COMPLETE IN TRIPLICATE) CT �s� � '�• � r`1 ,QUALITY 0,?-7 ® <br /> — VCS-DI <br /> Application is hereby madetothe San Joaquin Local Health District`fory ermitto 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 Joaquin Local Health District. <br /> Exact Site Address i <br /> ,q pa f v , +v t . City/Town �./ <br /> Owner's Name.S�(!N/tf�v ��'_ y_ Phone <br /> Address City <br /> ``��A/ License#�� Business Phone <br /> V 4 <br /> Contractor's Name .� � <br /> Contractor's Address Emergency Phone r ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L--- No +� ` <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION E] DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR��� <br /> REPLACEMENTO <br /> DISTANCE TO NEAREST: Septic Tank �- Sewer Lines u Pit Privy �" Q <br /> Sewage Disposal Field Cesspool/Seepage Pit fwn.-rO_ Other <br /> Property Line "_t Private Domestic Well Public Domestic Weil <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 /> 9?'rIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information +p�, <br /> ❑ GEOPHYSICAL Surface Seal Installed By: F' <br /> PUMP INSTALLATION: Contractor IQN/✓ e d S' Q 1�—�•� <br /> Type of Pump " <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 37'Mate Work Done IF <br /> i <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 /> fffi <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:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X � —� � Title: Dale: <br /> Dr wa Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE 1 4274-�x <br /> Application Accepted By - 1 Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ElJuVy 1 &Received <br /> EMIITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> 1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No f Issuan Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />