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FOR OFFICE USE: APPLICATION <br /> For Non-Transiereble,Revocable,Suapendable <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> .Application is hereby madeto 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 Z 21 4b __—�y!/��1'O ft ,� d. City/Town S' �e H �O . <br /> ,!.Owner's Name I I-4t J Phone 19 7— 3067Z, <br /> Address 6 City <br /> Contractor's Name GaµLic a N Business PhoneT��.3 <br /> Contractor's AddressEmergency Phone � [/ <br /> 'is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ' No ✓ t� <br /> TYPE OF WORK (CHECK): NEW WELLII DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ < <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Q PUMP REPAIR❑ 1 <br /> —REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank I ls" Sewer Lines Pit Privy C <br /> Sewage Disposal Field Cesspool/Seepage Pit Other Or <br /> r. Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL I �e <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation t <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing L~ <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12'1!0 of <br /> ❑ IRRIGATION K GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION RIROTARY Type of Grout QQ '►!•a'�y-fr <br /> e..❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 'r 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 /> 1 will call for yy9,,,Grout Inspection prior to grouting and a final Inspection. <br /> Signed { L Title: nr.L�e y- Date: ZS 7 � <br /> .,, (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I nJ,, /P',,� / �./1//f��� cy <br /> Application Accepted By f �r"""�'t--6n"/�" '� `�'� Data �S <br /> Additional Comments: <br /> Phase 11 Grout InspectionPhasePhase III Final Inspection <br /> Inspection By I" Date !I 1241�� Inspection By Y2�� Date - Q. six <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEELESS <br /> y� PRORATION `l 8. QD <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r - Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.9o.2009 STOCKTON,CA 95201 <br />