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FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance witrrh��San a uln o'u�jtx0,/r�din nice No.,A1662 an the!/rules and regulations of the San cJ�oauin cal Health District. <br /> Exact Site Address ._] �f V`! l�/�� pllC. ( RJ City/Town _—J /�////� <br /> Owner's Name F Phone 7,31 �—A -3 <br /> Address 044M f City S7(5riC la.-i <br /> Contractor's Name Lr'H ense# Business Phone di�¢ <br /> Contractors Address 20IrOallito, W Emergency Phone ^J6 U-n, <br /> Is Certificate of Workman's Compensation Insurance on Fie With SJLHD7 Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ GO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ S' /1,�(/�� <br /> DISTANCE TO NEAREST: Septic Tank ' �i 3/ 'S't'wdT Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other C <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State work Done r <br /> PUMP REPAIR: IN State Work Done 4C4— <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 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I II f t ns rior outing and a final Inspection. /� <br /> Signed X Title: ( / . rF J. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASEI �/A <br /> Application Accepted By .O" Date <br /> Additional Comments: <br /> Phase II rout Inspecillon hese III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July i a Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> r <br /> FEE 411y5� J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> tr O Z S <br /> —79 —`at o �l�7t Z j <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />