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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 011 A I, <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ..�.y- PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> x <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/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. I <br /> Exact Site Address ,agroo-0- City/Town — Ptd <br /> Owner's Name V-1455649 0_)eAZ_,F-A9_Z1 Phone <br /> iii { <br /> Address City <br /> - Contractor's Name LicenseO374-9= Business Phone nP270 i <br /> Contractor's Address Emergency Phone 7 <br /> u <br /> . is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No s <br /> TYPE OF WORK (CHECK): NEW WELLA DEEPEN 13 RECONDITION DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ 1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 160 Sewer Lines_ 160 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 /> �d <br /> ❑ INDUSTRIAL IA CABLE TOOL Dia. of Well Excavation A1^7- <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 ❑ ROTARY Type of Grout �LIJVr /I� � <br /> ❑ DISPOSAL ❑ OTHER Other Information �l l <br /> ❑ GEOPHYSICAL Surface Seal installed By: �ilf �. fiir/�ti cn <br /> PUMP INSTALLATION: Contractor H P -� ', I <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done_ n <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> l <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 /> I <br /> Contractor'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 all far a Gr t Inspectio ri to grouting and a final inspection. p �/ <br /> Signed X Title: Date: � /ra� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted $y Date <br /> Additional Comments: <br /> hase_IIl/70 in ection hasg �Ipecfion By Inspection By + 2— <br /> Inspection ��y2 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31.. ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE PATE REMITTED <br /> AMOUNT <br /> FEE <br /> } <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issitance Datb I Mailed Delivered <br />�`!� - APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ <br />