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Applications Will*e.Pmcessed When Submitted Properly Completed.Be Sure To Sign The:Application. <br /> ori: u APPLICATION <br /> r- = (For Non-Transferable,Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> "7770�,6 <br /> Application is hereby made to the San Joaquin Local Health District#ora permit to constructand/or install the work herein described.This application is <br /> made incompliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addresso2s" .�hl STY2 bAJ <br /> d City/Town , E� <br /> ,r <br /> Owner's Name L.4 k k 4y 14* Phone 535<- <br /> Address City 2- <br /> Contractor's <br /> Contractor's Name tfqq Ldo iv t . License# 3 f?)23 Business phone 44k-- 4 7 R, C�1 <br /> Contractor's Address aniaDot) Al. .SO,-,,GV i, Are, %rao Emergency Phone '�"�1Ac <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD?- Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑--' -DES`fRUCTION❑ <br /> WELL CHLORINATION❑ WELL ABANDONMENT ❑ -OTHER ❑ PUMP INSTALLATIONX- PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank b Sewer Lines 15�E7' Pit Privy <br /> Sewage Disposal Fi��e+ld� Alo&Ze. Cesspg/ol/Seepage Pit O N� Other <br /> - <br /> Property Line eass Private Domestic W@Il � •I(h- Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> El INDUSTRIAL.II°°NDUSTRIAL )<ABLE TOOL Dia. of Well Excavation / <br /> /a.DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �� Y <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout e'y'1^e +c/ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL —- - --- -- Surfa , . Install d By: <br /> PUMP INSTALLATION: Contractor t/1C `!{ '`'1 v 4e _ <br /> ` ` <br /> Type of Pump /^`» r . 'c2Fa. H.P. _ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done J <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mato'rrial 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 v <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 /> Contractor's hiring or sub-contracting signature certifies:the following:"1 certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to W-Mmanseompensation laws of California." <br /> call for a Grout I ectfon prior to grouting and a fiction. Q <br /> Signed X Title: Date: r <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted.By <br /> l�t Date <br /> Additional Comments: <br /> /-,Ph a u Iftrout Insp Ion P ase III Final Inspection <br /> Inspection By ate 2 , [/l� Inspection B , e v <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑_EACH ❑ January 1&Received By January July 1 &Received By July 31 <br /> i - <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE At <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 1 <br /> Received by ate Receipt No. PerrnwNo Issuance Date idled Delivered <br /> -- APPLICANT—RETURN ALL COPIES TO: E14VIA"ENTAL#EAL1H PERMWSERVIC0' -v: 11601 E.HAEELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />