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Application ly Will Be Processed When Submitted Proli4 Completed.Be Sure To Sign The Ap"pllcallA. <br /> FOR OFFICE USE: - APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY r <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 Joe uln Court Ord"nance No. 1862 and,t ules and regulations of the Sa> n Ruin Local Health District. <br /> Exact Site Address <br /> Owners Name <br /> City (riiyx,r �pIQ r <br /> Address P <br /> 1 . 86 <br /> Contractors Name �f�r���� City <br /> Contractor's Addre License 111 774 g Business Phone —O�: <br /> Emergency Phone '��""'� t <br /> Is Certificate of Workman's Compensation Insure eon FII It <br /> SJLHD� Yes L! <br /> TYPE OF WORK(CHECK): NEW WELL DEEPEN ❑ IO r <br /> WELL CHLORINATION ❑ RECONDITION❑ DESTRUCTIONQ�� y <br /> WELL ABANDONMENT❑ - OTHER ❑ PUMP INSTALLATION REPLACEMENT❑ CpUMP REPAR <br /> 13 <br /> DISTANCE TO NEAREST: Septic Tank �r7 t / t <br /> + � Sewer Lines /�n� pit privy � <br /> Sewage Dispo I Field, 11151l - Cesspool/Seepage Pit " <br /> _ Property Line _Private Domestic Well Public Domestic Well Other <br /> INTENDED USE r - TYPE OF WELL - <br /> ❑ IN USTRIAL --- --- <br /> �'�ABL-ET� <br /> OOL 4a S..O Die. Of Well Excavation_MPtOMESTIC/PAIVAT'E ❑ DRILLED Die. of Well Casing _9 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ /2 Cit- i ) <br /> 11 IRRIGATION f ) ❑ GRAVEL PACK " Depth of Grout Seal. �(� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY • o '1 •z. Type of Grout CjZT / <br /> ❑ DISPOSAL ( .:- ❑ OTHER <br /> CI GEOPHYSICAL Other Information .� <br /> ->� <br /> rface Seal In§felled By: ; <br /> PUMP INSTAL t ATInu Contractor <br /> Type of Pump <br /> PUMP REPLACEIIIEINT: ❑ State Work Done ^` <br /> PUMP REPAIR: ` �,<. <br /> 7 . 13 State Work Done <br /> 'ai'• <br /> DESTRUCTION OFQiLL: Well Diameter ~ ' proximate Depth h S <br /> . Describe.Material and Procedure <br /> a14,4. ote <br /> -i1 /)11.J u)�/1 -p <br /> I hereby.certify that 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 ce'AlHes the following:"I certify that in the performance of the work for which this permit G <br /> is issued, 1-'shall not employ an - 1 <br /> p y y pe7son in sueFi manner as to become subject to workman's Compensation laws of;Celifornia." <br /> Contraefti shiring or sub-contracting signature certifies the following:"I certify that in the performince of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California."I ! I <br /> I will 9411 lora Grout I 5FIAtl prlor to prouting end a final Inspection. ) <br /> Signed X. .. — Title: Date: .0—/0— k2-- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ` r <br /> PHASE 1 <br /> Application.Accipted By <br /> Additional Comments: ' o Date <br /> ' <br /> as IIf «"t-InspectIon�, p P,h>�e III.164t'Inspadion: <br /> Inspection By 1 f1 -xraat'8 F - - Q• I lJN�t (�i.✓�1� v�. > <br /> IVpyl a C� t'�'�J -! P¢C56y-0{;I�'w^bl.[T "+. Date . . y <br /> FN IB DYE:D NUALLy-�� PER UNIT ❑ PER SITE Q EACH i%❑f-�Jan�uj ry Q Rocaive;d By January 31 ❑ July I Qf Recalved By July 31 <br /> ti— 1 BASE EXPLANATION BILLING' •REMITTANCE Vs. REMIT <br /> DATE DATE REMITTED AMOUNT OUE CHECKED - <br /> AMOUNT'"- <br /> FEE <br /> LESS {r <br /> PRORATION [ t <br /> PLUS <br /> PENALTY <br /> OTHER. <br /> r <br /> OTHER <br /> Recei a 0Y DNe Receipt No. Permit No. Isauan Data Mallad Delivered <br /> APPLICANT—RETURN ALL COPITB T6. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.to axle STOCKTON,CA 15201 <br />