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i a Applications Will Be Processed When Submitted ProperlyCompleted. tae sure 10sign Inesrppncallvri. <br /> FOR�OFFICE U,SE:, . ;_-r. APPLICATION <br /> /*v44X (For Non-Transferable, Revocable, Suspendable) <br /> k. PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIIGATE)80Qg �+ .�.C4G7-o n� "TER QUALITY <br /> PL <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Co,unyj Ordinance No. 862 an the rules a d r lations of the San Joaquin Local Health District. <br /> Exact Site Address 4A►tcSv`O 6�- 4 ' ^71L City/Town <br /> Owner's Name '"6..t i�4t Phone <br /> Addresses 7 1 [m. l "� _ City ! <br /> Contractor's Name // License# t?-7— Business Phoney <br /> Contractor's Address Q &V Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File W h SJLHD? Yes.�_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN El RECONDITION F-1DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® <br /> REPLACEMENTS � <br /> i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy f� <br /> Sewage Disposal Field Cesspool/Seepage Pit Other y <br /> Property Line Private Domestic Well Public Domestic Well -f, <br /> INTENDED USE TYPE OF.WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ; <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED R Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> EEE f6 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout CIO <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL 'st wr Surface Seal Inst By: <br /> .. > <br /> PUMP INSTALLATION: q Contractor 3 0A/ <br /> �`✓ <br /> � Type of Pump H.P. <br /> s PUMP REPLACEMENT: w AI ❑ State Work Done t- <br /> PUMP REPAIR: ® State Work Done C _ <br /> DESTRUCTION OF WELL: q Well Diameter - ' Approximate Depth <br /> Describe Material and Procedure <br /> Y _ <br /> lS <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County lryc <br /> ordinances, state laws, and rules and regulations of the San Joaquin local Health District. <br /> Homeowner or licensed ageni'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'bec�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'co laws of California." <br /> ar> <br /> I w! call for a Grout Ins e p r to gr o tin` a a final inspection. <br /> tle: <br /> Signed <br /> yTi /@:� Date: <br /> (Draw RIO t Ian on Reverse Side) <br /> F R D ARTME T USE ONLY <br /> PHASE i <br /> Application Accepted By — Date <br /> 1 <br /> Additional Comments: <br /> Phase II Grout Inspection t se 111 Final In pection <br /> i Inspection By Date Inspection y Date `LL <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNiT ❑ PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 0 July, &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> D DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> R PLUS ' <br /> PENALTY <br /> OTHER <br /> OTHER' <br /> Received by Date 4 Receipt No. Pere issuance Date Mailed Delivered <br /> APPLICANT—RETURN AtL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICEs 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />