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FOR OFFICE USE: / G APPLICATION <br /> Co.L+b�0 (For Non-Transferable, Revocable, Suspencia <br /> 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. 1892 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /9'�0 0/7 // JF R`[� A0 �fi City/Town ,^.A� <br /> Owner's Name [/� s� /7jlFHQ/i A Phone 441 <br /> CDP <br /> Address Z!2ze '� '� C....-sJ C! City-' ca <br /> Contractor's Name ! sftLi ense# Yt2 71 "Business Phone 44dil 7 <br /> Contractor's Address e;LO OIL Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit LHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <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 Cesspdol/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 On <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout V <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 <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 /> Home owner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> j011 call for a Grout Inspectio doeflo.groi Ing and a final inspection. <br /> Signed If 57-fisial J0, <br /> life: Q/a6/ Date: / <br /> (Draw Plot Ian on Reverse Side) <br /> FO DEP RTMEN SE ONLY <br /> PHASE I /J d <br /> Application Accepted By a% Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date <br /> � Inspection By Date <br /> 11u <br /> Fee Is Due: ANNUALLY ❑ PER UNIT V 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 /> FEELESS <br /> S v <br /> PRORATION J <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. lss,umcd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,CA 95101 <br />