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-T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION -E r <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL f <br /> ENVIRONMENTAL HEALTH PERMIT (Y 1 <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> _. ) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and <br /> /orinstalltheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin Coun!y Ordinance No 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town 4A 4/04 <br /> Owner's Name Phone <br /> Address �'s�/-/ City <br /> <, , <br /> Contractor's Name c�,� A License# —f/ Business Phone 5z 4 i -2 ells <br /> Contractor's Address c„Zr.1/ & � z Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With.SJLHD? . Yes X _ _ No <br /> TYPE OF WORK (CHECK): NEW WELLA DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑- PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ 1 f <br /> DISTANCE TO NEAREST: Septic Tank f Sewer Lines ISD -E Pit Privy <br /> Sewage Disposal Feld;i> Cesspool/Seepage Pit Other �-- <br /> Property Line Q. _ Private Domestic Well 40--E Public Domestic Well <br /> INTENDED USE TYPE OF WELL r� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing _ / <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing —JG/A S �� <br /> ❑ IRRIGATION ) GRAVEL PACK Depth of Grout Seal �[7 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 0 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> LE--F-7 1'0� rZP rc' _ G <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 /> 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 forwhich this <br /> permit is issued, I shall empl persons subject to workman's compensation laws of California." <br /> I will call for r In a on prior to grouting and a final inspection. <br /> Signed X Title: _ Date: 5 / <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY ([ p <br /> PHASE I C1�/�.F Date <br /> Application z <br /> Application Accepted By <br /> Additional Comments: <br /> PPh se I Grout In ection P I,I Final Inspection v <br /> Inspection By �'" ate ®2-' 4 � '/ Inspection By "��� Date �-�S � <br /> r Fee IS Due: El ANNUALLY ❑ PER UNI ❑ PER SITE ❑ EACH ❑ January 1 &Received 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 /> FEE �3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 779 1 3 0 7 <br /> Received by Date Receipt No. Permit No., Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: �ENVIRONMENTAL HEALTH PERMIT/SER <br /> VICES' '1601 E.HAZELTON AVE.,P.O::Box 2009 STOCKTON,CA 9520 <br />