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_ <br /> _v.:- Applications Will Be Processed When Submitted Proper y omp e e <br /> FOR OFFICE USE: APPLICATION <br /> i <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> V. ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> uin Local Health Districtfor a permit to construct and/or install the work herein described.This application Is <br /> Application is hereby made to the San Joaq <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regula#�ons of the San Joaquin Local Health District. <br /> / { l `'� is{Ir- City/Town _ <br /> Exact Site Address-#A <br /> �✓ �-•r F� '� ",�,,..-�,t IFS�` ,fl r.;r J'1 �it.1 r r �� �.�Y,- r <br /> Owner's Name 0 kk i (_ ` ? ` Phone G" <br /> `' �, r t, v . t . �4 City <br /> Address ��' Ale- <br /> Business a <br /> Contractor's Name �•.�• � ''ti <br /> License# Phone <br /> Contractor's Address 1 4.�_frA Emergency Phone <br /> Is Certificate df Workman's Compensation Insurance on File Wi SJLHD? Yes _— <br /> No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTiON❑ j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRI <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Other <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION C1 GRAVEL PACK Depth of Grout Seal _ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout C] <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed ByT <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done lCounty PUMP REPAIR: State Work Done �-�r - . ''' ° ,,DESTRUCTION OF WELL: Well Diameter <br /> Approximate DepthDescribe Material and Procedure I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaq <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 /> ure certifies the following:"I certify that in the performance of the work forwhich this <br /> Contractor's hiring or sub-contracting signal <br /> s compensation laws of California. <br /> permit is issued, I shall employ persons subject to workman' " <br /> I will call for a Grout inspection prior//to grouting and ae irial inspection. t <br /> Zlotiv�. <br /> Date: 4� f4 <br /> 1fle:5i nedXgP an on Reverse Side) <br /> J .1' <br /> FOR DEPARTM T USE ONLY n <br /> PHASE I i rr �... n Date �6Z <br /> Application Accepted B <br /> p YT, <br /> Additional <br /> Additional Comments: J�f-`'� 'F '� t <br /> Phase II Grout Inspection t f ` Phase III Final inspection <br /> Inspection By <br /> Date Inspection By Date <br /> January 31 July 1 &R <br /> Fee IS DUE: ❑ ANNUALLY ❑ PER UNIT T❑ PER SITE ❑ EACH [❑ January 1 &Received By (� ecely July 31 <br /> REMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE 'REMITTED - AMOUNT <br /> FEE 1 o .s "o✓. i It c s:, A. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received try"� <br /> D e Receipt No. Permit No, ` Issuance.Date Mailed Delivered <br /> YE.,P.O.Box 2805 STOCKTDN,CA 95201 <br /> APPLICANT—RETUaN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., , <br />