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Ata&'Alfil 'OrogeseW Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: NOV APPLICATION <br /> f OV I 198�or Nan-Transferable, Revocable,Suspendable) /' PUMP&WELL <br /> rSAN <br /> VONMENTAL HE'ALT'H PERMIT <br /> iomLOCAL [/ <br /> (COMPLETE IN TRIPLICATE - H ®! - � WATER QUALITY <br /> j�' <br /> Application is hereby made to the San Joaquin oca ealthDistrictforapermittoconstructand/or install the work.herein described.This application is <br /> 4 <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 Q Vv � 1'+'C-4 LGA City/Town GK ' <br /> .� <br /> Owner's Name ?�©Ylt;�."t. fy�'IQ,CArado Phone r' <br /> Address -i+P i ,. : : ", City- <br /> Contract <br /> ity 9t Qom{ <br /> Contractor's Name - l % License#3711040 Business Phone � c�'� :24 <br /> Contractor's Address _ Emergency P one I 'll _ <br /> Is Certificate of Workman's Compensation i1nsurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK) NEW WELL❑ DEEPEN ❑ RECONDITION❑Y DESTRUCTION❑ y �' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 1 <br /> r. REPLACEMENT1a <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy lX= <br /> Sewage.DispyosalvField Cesspool/Seepage Pit Other 4 <br /> T Property Line —Private Domestic Well Public Domestic Well <br /> INTENDED USE 1 TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation J� <br /> D<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 ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER k Other Information <br /> []-GEOPHYSICAL «- Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. f n <br /> PUMP REPLACEMENT: State Work Done S- <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <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 /> { <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 /> for a Grout Inspec ' ri prior grout' and a final inspection. <br /> F' Signed X Title: _ -� _-•Date• • 'a�� - <br /> I (Draw Plot Plan on Reverse Side) . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ~"[� Q <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Fi at Inspection <br /> Inspection B 1w n Date Inspection By /� v Date <br /> i Fee Is Due: ❑ ANNUALLY - ❑,PER UNIT " ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> I _ _ _-_--� BILLING .: REMITTANCE $ <br /> !BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _ AMOUNT <br /> FEE r <br /> LESS <br /> PRORATION - _! <br /> PLUS J _. .> .... <br /> PENALTY'. <br /> 4 OTHER i <br /> OTHER a r: <br /> Received by -w Dale - Receipt No.'>� +- Permit No, (�•- - 'Issua e Ddle Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> a <br />