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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .,FOR OFFICE USE: APPLICATION <br /> 4F 66sa.0 a� (For Non-Transferable, Revocable,Suspendable) 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 Ordi anc�e♦NP. 1862 and the rules antl regulations of the San Joegyin LOD Health District. <br /> Exact Site Address A�3y S e7T/Qf pre- �e e9 b CityJTown r•A(A e( <br /> Owners Name y tASI 2--_ . Phone <br /> Address / 1'A4' am Ant WAN 41111 Aces,4b City j6w—, <br /> Contractors Name 1LLN ­1LLicense# /fil —7&VT Busine rs Phone rl6 t- " 7 G 7 W <br /> Contractors Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes—,,11C No t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIRZ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> t 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 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor SlI <br /> Type of Pump 4jI .r H.P. 3 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 191 State Work Done CJi.a R• 11Wrd b 46 C ._ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 1 havepreparedthis 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 tollowing:"I certify that in the performance of the work for which 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 /> Contractors hiring or sub-contracting signature certifles 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 vglll call for a Grout Ina to p Qr to fouting an a final Inspection. <br /> Signed X 1 d �•� '�Tlge: ��l' Date: <br /> (Draw PI Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepts y f 'r Date'dT -�2 - <br /> Additional Commen <br /> Phase 11 G o t action AmIved, <br /> e I fns Inspection <br /> Inspection By Date Inspection BDate <br /> Fee 19 Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Rnuary 31 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 4 �— <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 153,60 4a <br /> Received by Due Receipt No. Permit No. Inuan.1,Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES I Wt E.HA TON AYE,P.O.see 2eee STOCKTON,CA 9M1 <br />