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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1 <br /> FOR OFFICE USE: APPLICATION , I <br /> _ (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> .• <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPL+ETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.ih&, ed.T s ppi&ti n' iss <br /> made in compliance w' San oaquin County. dinance No.186 and the rules and regulations of'th'e San-4paDi quin Local Health riot. <br /> Exact Site Address , _ S mc _ � v <br /> Owner's Name z r:10 E 4Phone <br /> Address -54,9 Z&" City <br /> Contractor's Name .IZ t Pfl�r.4,icense# . t Business Phone _ <br /> Contractor's Address "J - �J Emergency Phone i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Q4 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER� .PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT E] y ° <br /> DISTANCE TO NEAREST: Septic Tank ✓ Sewer Lines""---Pit Privy <br /> Sewage Disposal Field e /o r1 11-1 Cesspool/Seepage Pit ,___. _ __ Other <br /> Property Line_ZQ Private Domestic Well T (' Public Domestic Well t <br /> INTENDED USE -TYPE OF WELL _ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL .. 'Dia-of`Well Excavation. <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED W x Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ c-I j 4e) } I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of•Grout.Seal_� J+ <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout i rA, z. birr , 3 r <br /> ❑ DISPOSAL ❑ OTHER LAG-'11D9/rti3O Other Information- <br /> 11 <br /> nformation-❑ GEDPHYSICAL Surface Seal Installed By: e!2+ F+4 <br /> PUMP INSTALLATION: Contractor <br /> f I Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP'REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> Home owner or licensed agent's signature certifies the following:"I certify tHai t 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:`4_, <br /> Contractor's hiring orsub-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 /> y <br /> I will.call- qr a Grout InspOtlon tor, routin and a final-ins ection. <br /> SignedXs -Title:-- _ — ..Date. +� C <br /> (Draw Plot Plan on Revery Side) 1 <br /> FPR DEPARTMENT U�SE�ONLY <br /> PHASE I \a, � 'i t � 1c),N".N <br /> Application Accepted By " Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE f EXPLA TIONAMOUNT DUE CHECKED ° { <br /> f DATE DATE REMITTED AMOUNT <br /> FEE <br /> ,r C� <br /> LESS t <br /> PRORATION <br /> PLUS <br /> PENALTY - . <br /> OTHER • -.�` <br /> 1 i3 <br /> Receiv y atek Receipt No. - Permit No. Issuan a Date' ' Maited Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />