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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> FO1r!OFFICE1USE: 1v? 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 for a 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. 1 <br /> Exact Site Addresses � City/Town 1110 tYOP10 <br /> Owner's Name <br /> Phone 3 Co 9-7 9 6 F f <br /> Address 0/ /1 7 ze j City ./A4 <br /> Contractor's Name zu__ License#3370902 Business Phone -76-97 3 3-7 <br /> Contractor's Address ���a)C �� - Emergency Phone 7SV—345-S' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No Q .• <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION-b DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER El 'PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ /540 /So <br /> DISTANCE TO NEAREST: Septic Tank-__-7 " - --Sewer Lines Pit Privy <br /> Sewage Disposal Field - Cesspool/Seepage Pit Other <br /> Property Line 5,�V Private Domestic Well 3Public Domestic Well <br /> INTENDED USE TYPE OF WELL I <br /> ❑ INDUSTRIAL CABLE TOOL .: Dia. of Well Excavation �aF/ 57_ 6-01 <br /> DOMESTIC/PRIVATE ❑ DRILLED 6 Dia. of WeII:Casin <br /> 9 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACKy Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 13ROTARY s Type of Grouter <br /> ❑ DISPOSAL ;. ❑ OTHER �' Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALL Contractor 6110-501y l,(/F1�. <br /> " I Type of Pump H.P. S _ <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 /> ( <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 /> Home owner or licensed agent's signature certifies the following:"1 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:"I certify1hat in the performance of the work for which this 't <br /> permit is issued, I,shall employ persons subject to workman's compensation laws of California." ' <br /> I wilA call for a.Grout Inspection pr' r to grouting and a final inspection. <br /> Signed <br /> �/ p <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: ,l <br /> e II Grout Inspection / Q'� / P III Final Inspection <br /> Inspection Bi Date rw� !! Inspection By� Date <br /> Fee Is Due: 1:1 ANNUALLY El PER IT El PER SITE 11 EACH El January.l &Received By January 31 ❑ July 1 B Received By July 31 <br /> ' - REMIT <br /> BILLING. REMITTANCE 1 $ <br /> BASE EXPLANATION DATE' DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> --T' -.'FEE - U ... .... .YP Q�•t�� - --._ -� <br /> LESS <br /> PRORATION o <br /> PLUS <br /> . PENALTY <br /> OTHER { <br /> 1 <br /> OTHER~ ! 1 <br /> Received by ilate Receipt Nc. Permit No, - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />