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Applications Will Be Processed;iihen Submitted Properly Completed. Be Sure To Sign The Application. j <br /> FOR ,_-FILE USE: APPLICATION IE <br /> - - ,,(For Non-TransferableRevocableSuspendable) i <br /> . PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> QUALITY <br /> (COMPLETE IN TRIPLICATE) WATER Q p <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work,herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addressy� �J Q° !YI 3l'I R/ /czlo_B1941City/Town Ik <br /> . . <br /> � w <br /> Owner's Name U 14 7 Phone 744- z Z'6" � <br /> Address City S D c74f 11 <br /> Contractor's Name 0&ore £� er ! License#/OE- '?Av Business Phone K'9/G/ 37/—fi 2-?4 <br /> Contractor's Address Emergency Phone Q <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No IIS <br /> TYPE OF WORK (CHECK): NEW WELL 0 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �` <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ l n <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other li' <br /> Property Line Private Domestic Well Public Domestic Well I <br /> INTENDED USE TYPE OF WELL II <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing II <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal e I <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout I� <br /> ❑� DISPOSAL 13OTHER Other Information <br /> { IM <br /> X2 GEOPHYSICAL Surface Seal Installed By: II <br /> PUMP INSTALLATION: Contractor II <br /> Type of Pump H.P. IM <br /> PUMP REPLACEMENT: ❑ State Work Done I� <br /> PUMP REPAIR: ❑ State Work Done I� <br /> DESTRUCTION OF WELL: Well Diameter 9pproximate Depth IM�Q1-7 <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 /> �II <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. IIII 1 <br /> r <br /> Home owner or licensed agent's signature cerlifies 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 /> will c I for a Grout I ection p for to ting and a final inspection. <br /> Signed X Title: <br /> II (Draw Plot Plan on Reverse Side) USG/; y �CrP IIaG e <br /> FOR DE ARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: I <br /> Phase It Groul.1nspection Phase Ill Final Inspection <br /> inspection By_4 d Dg& Inspection By <br /> .r <br /> I r 1 Received B Januar 3t Jul' i &Received B Jul 3t <br /> Fee 15 Due: ❑ ANNUALLY ❑ PER UNIT El SITE El ❑ January & y y ❑ y y y � <br /> I REMIT <br /> BILLING REMITTANCE $ <br /> Ij BASE EXPLANATION AMOUNT DUE CHECKED <br /> ff DATE DATE REMITTED rl AMOUNT <br /> FEE ri <br /> LESS <br /> _PRORATION <br /> r <br /> .1 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ni <br /> OTHER �Ilr <br /> o53 <br /> -­ b 1 _ <br /> Received by Date Receipt No. Permit No Issuance Date Mailed NN De}ivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 rIR STOCKTON,CA <br />