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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR-OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELLr I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permit to construct and/or install thework.herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ® �j0 V City/Town FRE C <br /> Owner's Name �21?GL,-?'' Phone q6) - <br /> 1 <br /> Address ' City <br /> ��f Qfl7R1i r2 � License# Business Phone WA/ <br /> Co s -f ,") Emergency Phone k <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ -too, Sewer Lines Pit Privy <br /> • "�- M- Sewage Disposal-Field CQ'--- -_ Cesspool/Seepage Pit t40tOther <br /> Property Line 166- Private Domestic Well y Public Domestic Well <br /> INTENDED USE -TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation I <br /> j ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Wel Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seaf <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ` <br /> ❑ DISPOSAL ❑ OTHER ( Other Information�T <br /> ❑ GEOPHYSICAL 1 ~''x Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 0WAW_"_ <br /> Type of Pump Fi.P.�+iw Gt �� ob <br /> PUMP REPLACEMENT: ❑ State Work Done - <br /> PUMP REPAIR: ❑ State Work Done ! <br /> DESTRUCTION OF WELL: -Yell Diameter '� f Approximate Depth <br /> PLA 16-1escribe Mat rial and Procedurew <br /> L W CL LIL� A F i J,7A-rJ& A Y e I <br /> I hereby certify that I have prepared this ap /cation and tKat 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 iolowing:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such mariner 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 /> I w- cal for a Grout I spec ' n prior to grouti g and a final inspection. <br /> Signed XTitle: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I L Z_.157 Date <br /> Application Accepted y <br /> Additional Comment <br /> Phase 11 Grout Inspection P09se III Fin Inspection <br /> ! Inspection By Date Inspection By� Date <br /> 4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ 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 BATF REMITTED AMOUNT <br /> 0 <br /> FEE. j <br /> LESS - - - <br /> PRORATION <br /> PLUS <br /> + PENALTY, <br /> OTHER <br /> OTHER /J /�}� �y.y�� !( , <br /> Received by Dae Receipt No• Permit No I Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D1 <br />