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Applications Will Be Processed When Submitted Properly Completed. Be Sure'To Sign The Application. <br /> FOR OFFICE USE: j� APPLICATION _ <br /> d <br /> I� (For Non-Transferable, Revocable_,Suspendable) <br /> n''•""--•:� " PUMP&WELL !. . <br /> j ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) jj; WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 wd the rules and regulations of the San Jo quip Local Health District, <br /> Exact Site Address 7 '7.� ;!E [�� _ City/Town �Eci _ <br /> Owner's Name Phone <br /> Address City c <br /> Contractor's Name .2 License Business Phoney <br /> Contractor's Address p!�'b/3 uAaj Emergency Phone I <br /> is Certificate oflWorkman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE Of WORK,(CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ J <br /> WELL CHLORINATION'❑.gam: NVELLI ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank lod 17{ Sewer Lines /Cc)c) rt Pit Privy <br /> r Sewage Disposal Fieid—/60 Cesspool/S epage Pit Other -P <br /> Property Line/D Private Domestic Well sPublic Domestic Well <br /> INTENDED USE jI TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavations <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing aeg uJ£�� <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION I!j ❑ ROTARY Type of Grout �— <br /> ❑ DISPOSAL IJ ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL II Surface Seal Installed By: 0cc)MAr,:z } <br /> PUMP INSTALLATION: !p Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 3I ❑ State Work Done <br /> PUMP REPAIR: <br /> ❑ State Work Done +t ' <br /> DESTRUCTION OF WELL: I Well Diameter Approximate Depth <br /> i 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 k <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 for which this <br /> permit is issued, I shall ern ploy ersons s jest to workman's compensation laws of California." I <br /> I willa Grout I ecti yprio grouting and a final inspection. I <br /> Signed X Title: Date: i� <br /> jl (Draw Plot Plan on Reverse 'de) <br /> . t <br /> i! FOR DEPARTMENT USE ONLY <br /> PHASE ! Y <br /> Application Accepted By oe g=va Date 31!5/80 4 <br /> Additional Comments: �� <br /> Phase II 'Grout Inspection Phgse III Final Inspection _ 1 <br /> Inspection By 4 Date Inspection By • Date <br /> Fee Is Due: ❑ ANNUALLY ❑'i.PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - - - REMIT <br /> I -BILLING REMITTANCE $ <br /> BASE EXPLANATION �` ED AMOUNT DUE CHECKED <br /> DATE DATE REMITT <br /> _ + AMOUNT � <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS —�� -- - ..r <br /> i <br /> PENALTY II <br /> OTHER <br /> OTHERo <br /> 1 <br /> III,--14 Ls L d . <br /> ti Received-by Date �­Receipl No. Permit No:­-- r Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALLY PIES TOO: ENVIRONMENTAL HEALTH'PERMIT/SERVICES 1601 E.HAZELT6N : <br /> AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> Y o <br />