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I-AN <br /> Iical@@pYiJseed When Submitted Properly Completed. tae Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> SAN JOAQ IN LO (LFALNon-Transferable, Revocable,Suspendable) � PUMP&WELL <br /> HEALTH DISTRICffNVIRONMENTAL 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 theiSan Joaquin Local Health District. <br /> Exact Site Address " City/Tpwn <br /> Owner's Name Tis Phone a 84F 7 '-,;T 97� <br /> Address . ' City l--,E7 <br /> Contractor's Name c License'# -Z.&&E6 Business Phone <br /> Contractor's Address --Z(,e-7 e-C7 _/QCT Emergency Phone % p A <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - No qJ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DES <br /> ❑ 1 TRUCTION❑ ! <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> ` Sewage Disposal Field Cesspool/Seepage Pit Other <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 ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION i ❑ ROTARY Type of Grout a <br /> ❑ DISPOSAL ( ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor - � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter— Approximate Depth 1620 <br /> Describe Material and Procedure. G — <br /> t ' wizzy , <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. 5 <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 /> Cot tractor'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 will calll`�fQr a Grout Inspection prior to grouting and a final inspection <br /> Signed X � 1 f�•- _ -Title: . �...— Date: <br /> (Draw Plot Rlan on Reverse Side) <br /> C <br /> IFOR DEPARTMENT USE ONLY <br /> PHASE ' <br /> .Application Accepted By J 01 I Date <br /> Additional Comments: } t <br /> NN <br /> II Grout Inspection Pgas�lll Fi el inspection <br /> 11 <br /> Inspection By� 1-{l Datef Inspection By �( Date <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 !O� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> A s ��-- <br /> Received by Date Receipt No. Permit No. ssuanc .Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />