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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> k (For Non-TrAnsferable, Revocable,Suspendable) m� <br /> PUMP&WELL <br /> I ENVIRONMENTAL HEALTH PERMIT <br /> C (COMPLETE IN TRIPLICATE) - WATER QUALITY . <br /> Application is hereby madeto theSan Joaquin Local Health District fora permitto construct and/or install thework herein-des'CAA This application is <br /> I made in compliance with San. Joaqui C my nan No.,1 62 an the �ules nd ul�ity/To��n' <br /> S�i h District. <br /> r <br /> Exact Site Address Q� /� hyo[ <br /> ._ <br /> e _ <br /> Owner's Name IY1 Oh Phone �� 79 <br /> _ L <br />` Address 0 City 7/-Z? '" <br /> Contractor's Name h/ 125,P05. License# 1 Business Phone .5"545//8� <br /> Contractor's Address Emergency Phone 5Y_ 4) Z 7 <br />! Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br />! TYPE OF l4ORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACErNENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank 00 `f" Sewer Lines Pit Privy <br /> Sewage Disposal Field /V��' Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �i { Q <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation�l <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing CACA <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing z6a &.;a <br /> ❑ IRRIGATION GRAVEL PACs( Depth of Grout Seal � {� <br /> ❑ CATHODIC PROTECTION *ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br />} PUMP INSTALLATION: Contractor <br /> k Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done_ <br /> PUMP REPAIR: ❑ State Work Done rp <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 /> Home owner 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 shalt employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout I ection plr�t groutin nd a tini spection. <br /> f Signed X C Itis412 , Date: 9-le_7 <br /> (Draw Plot Plan on Revers i e) <br /> FORD PARTME T USE ONLY <br /> j PHASE <br /> I Application Accepted By Date 7 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection Fly D t f <br /> Z <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ElPER SI El ❑ January ceived By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> PEE 3 <br /> [ LESS <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 00 q1 _ 01/- If f q rr f?y <br /> Received by Dae Receipt No. emitfNb. Issuance 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 />