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! <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,5uspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMA&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is herebymadeto theSan 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 Ordinanftee No.1882 and the rules and regulations of the sapJoaquin Local Health District. <br /> Exact Site Address�0/ s. City/To <br /> Owner's Name o Phone �- Q Co <br /> Address d -- s_ City <br /> Contractor's Name LlcenaeZ-(QO -C / Business Phone <br /> Contractor's Address — mergency Phone Fq <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes 4-1 No <br /> TYPE OF WORK (CHECK): NEW WELL 0--'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ -` <br /> REPLACEMENT© ` N <br /> DISTANCE TO NEAREST: Septic Tank _�'1 C)�-�- Pit Privy <br /> Sewer Lines./6 O --�� <br /> Sewage Disposal Field Cesspool/Seepage PitOther r^—^ <br /> Property Line Private Domestic Well Public Domestic Well Ca <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL <br /> ❑ GABLE TOOL Dia.of well Excavation <br /> ❑ DOST <br /> MIC/PRIVATE ❑ DRILLED Dla,of Well Casing ' <br /> Eg-150—MESTICYPUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal D <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER O P9EAr" IS 4�- Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed B <br /> PUMP INSTALLATION: S' y' -rte P SMC• -- — <br /> Contractor , <br /> Type of Pump H.P. <br /> 0 <br /> PUMP REPLACEMENT; El State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 became 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, sons subject to workman's compensation laws of California." <br /> will call for a Grout s c o .ptfo to grouting and a final Inspection. l� <br /> Signed y { (2 F� S 5 6 <br /> Title:_ < df� , <br /> Date: <br /> (Draw Plot Pian on Reverse Side)' ~�— <br /> FO DEPA MENT SE ONLY <br /> PHASE t <br /> Application Accepted By <br /> Additional Comments: Date <br /> lase 11 Grout inspection /PIh--as--a!tl FI11a1 Inspectionlnspeclion Date - Inspection By � � _ Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE [] EACH .a Janvary 1 3 Received By January 31 ❑July 1 d Received By July 31 <br /> BASE EXPLANATION SICCING REMITTANCE § REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEEr/CJ1 �`_J. AMOUNT <br /> LESS u (JCA <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C.- 6 <br /> Received by Date- <br /> Receipt No. Permit No. fttfance Date Mail ad ! <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES Delivered <br /> . •. L -_—.- ,Sol <br /> !",HATELTON AVE,P.O.Boa 2U0➢ $TOCKTON,C49 <br />