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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE 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 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 Parcel City/Town —1-,nd-i <br /> Owner's Name Steve P nnA Phone 951-1609 <br /> Address City Stockton <br /> Contractor's Name Mnnrman r License#267696 Business Phone <br /> Contractor's Address 2120 WillCOX Rd. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes xx No <br /> 1 <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION 1:1 DESTRUCTION❑ V ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION} PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank � Sewer Lines Pit Privy! �� <br /> A90Sewage Disposal Field `� Cesspool/Seepage Pit gO 6 &"-- Other " <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation,�Zf�f2G'�f <br /> 9 DOMESTIC/PRIVATE M-16RILLED Dia. of Well Casing rG�G�t <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ,❑,�, GRAVEL PACK Depth of Grout Seal <br /> C1 CATHODIC PROTECTION LbROTARY Type of Grout - j�!,UXACA1 <br /> ❑ DISPOSAL ❑ OTHER Other Information W <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor MOorman 1 S Water Stem <br /> Type of Pump submer aib I P 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will//call for a Grout Inspection prior to grouting and a final inspection. n <br /> Signed X Lrt -�%%�iy� Title: �!� `�1, ��/ Date: Z�� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accept By Date <br /> Additional Comme 17 K <br /> Ph e i G out Ins ecti PI�Flnalection <br /> Inspection B� ate Inspection ByDate <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 DATE REMITTED AMOUNT <br /> FEE <br /> S� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> OTHER 1J <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />