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R OFFICE USE: - I) APPLICATION Ca r-C-91 r�L <br /> (For N( ransferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> PLETE IN TRIPLICATE) WATER QUALITY <br /> ation 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 /> in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Site Address /�� ,L <br /> � City/Town Z C C �74--o-V <br />'s Name Phone .7. <br /> is 13 city�p k C <br /> actor's Name icense#2"7— BusinesssPho`ne 4, <br /> actor's Address 6 _ Emergency Phone`Wo <br />`ificate of Workman's Compensation Insur ce on File With SJLHD? Yes f..� No <br /> OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br />"CEMENTIL, <br /> NCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> s <br /> Sewage Disposal FielderI Cesspool/Seepage Pit Other ALI +. .. <br /> Property Line- Private Domestic Well Public Domestic Well � _2zS <br />'.TENDED USE TYPE OF WELL <br />)USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br />:MESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> iIGATIQN ❑ GRAVEL PACK Depth of Grout Seal <br /> THODIC PROTECTION ❑ ROTARY Type of Grout <br /> iPOSAL ❑ OTHER Other-information <br /> OP.HYSICAL Surface Seal Installed y: <br />'INSTALLATION: Contractor <br /> Type of Pump wS' ., <br /> REPLACEMENT: 01-state Work Donee <br /> REPAIR: ❑ State.Work Done <br /> IUCTION 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 /> Horne owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, 1 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t will all f'or a Grout nspect! tier to grouting and a final inspe <br /> X Title: Dale: _ <br /> l 1 (Draw Plot Plan on Reverse Side) <br /> i FOR DEPAR MENT USE ONLY <br /> 4HASE i � � <br /> pplication Accepted By Date <br /> 4dditional Comments: x :=k• <br /> Phase !I Groat Inspection Phaj�III al Inspection <br /> Inspection By Date " CInstpection By/0"_ <br /> i ate ! <br /> ... u�__, <br />=ee IS,DUe: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Received By January-31 ❑ July 1 &Received By July 31 <br /> ' BIWNG REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> LESS <br /> iaRORATION <br /> aLUS + ' <br /> i'ENALTY <br /> DTHERr <br /> aTHER{. <br /> © 5 3, _ .:;L <br /> Received by Date Receipt No.; <br /> Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1091 E.NAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />