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ftPPO14a1lUlli ►►111 UC r1U\.easmu ►►hell JUUIIHRCU rl UFltlny %,VlllIJleltlU. oe OUge L $IlJn Ine PlhPnUMIU4I <br /> FOR OFFICE USE: APPLICATION <br /> ,..•(For Non-Transferable, Revocable, Suspendabl <br /> -- ENVIRONMENTAL HEALTH PERMIT RUMP&WELL <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. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address (�!_,_/a'a_C_Atyd_� City/Town ��JLC <br /> Owner's Name 171, �f_. � Phone 4�.�r,�-{� C7_Z— <br /> Address �� 4� L11� �A_(!S:_ s� r�qc� City <br /> el <br /> Contractor's Name C"d icense # Business Phone ___ <br /> Contractor's Address mergence <br /> Is Certificate of Workman's Compensation Insuran eon File With SJLHD? Yes No ��nn <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ U It <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ U) <br /> REPLACEMENT E�� I C� <br /> DISTANCE TO NEAREST: Septic Tank �.�1 7� _ Sewer Lines Pit Privy <br /> Sewage Disposal f=ield�a'[dr I Cesspool/Seepage Pit Other__ <br /> Property Linea Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> f❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ,y�+�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: r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Teob A4 / H.P. <br /> PUMP REPLACEMENT: 'State Work Doner /L�' =firmer oil <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 /> Homeowner or licensed agent's signature certifies the following:"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 /> 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, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grwt Inspection prior to grouting and a final :20,40111— <br /> Signed X TitDate: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ay����QJ1��r�� _ � �-7 Date 7-7-;�- <br /> Additional Comments: <br /> Phase II Grout Inspection PhInspection <br /> Inspection By Date _ Inspection By Date —r- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 ❑ July 1 &Received By July 31 <br /> -- - - — --- --- ---REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATIpN AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> n el <br /> Received ay Date Receipt No. Permit No. ss once Dai Mailed Delivered <br /> APPLICANT--RETURN ALL COMES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Boll 2009 STOCKTON.CA 95201 - <br />