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FOR OFFICE U61 1 <br /> �gqrA��caacu num, uuuuc..cu rwycuT v.urupmcu. oc ame ru myn rue wypucaum,. <br /> d tJ 77t APPLICATION <br /> rpt � ,(FAr Non-Transferable, Revocable, Suspendable) <br /> K PUMP &WELL <br /> 11� 61SSpijG-JENVIRONMENTAL HEALTH PERMIT <br /> (C^L:PLETE IN TRIPLI60 I WATER QUALITY <br /> 11-Applicalion is hereby made to the San Joaqui In Local h District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance ith an Joaquin County Ord it a No. 1862 and t e r es nd egulations of the Sar�,Joaqujn Local Health District. <br /> Exact Site Address +^y�� / "f J -�q v City/Town " <br /> 60 Owner's Name �fJ ah e N cS ` Phone <br /> Address 12 5' g7 r_- � @ r 19/ City - <br /> Contractor's Name Cbm � M [�S C/.-fes r�, e.s_& License#/S4.'3i Z C_ Business Phone 7 V J / 4/ 7 <br /> III. O. <br /> .Contractor's Addre)C;'_; �(� 51p z & <br /> K W 6 4 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ rn <br /> REPLACEMENT❑ v <br /> DISTANCE TO NEAREST: Septic Tank N b Sewer Lines A-) Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> ►� Property Lines Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL , I/ <br /> ❑ INDUSTRIAL 1915ABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ZOMRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> s- ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL -T-�-� Surface Seal Installep By: <br /> PUMP INSTALLATION: Contractor <br /> �. Type of Pump Zz ° T+ H.P. c� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth - <br /> Describe Material and Procedure <br /> 0 L <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> r. 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 forwhich 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, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> �' A � <br /> Signed JCw-��f�� �""�"-t Title: `y�-5-- -�- �" Dater P,�_ <br /> (Draw Plot Plan on Reverse Side)- - - - "' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By � <br /> Additional Comments: 4'~ W <br /> Phase II Grout Inspection hese I F' Ins ection <br /> Inspection By Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNI ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE E REMIT <br /> La BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> L LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> 4 4 OTHER / <br /> OTHER J <br /> to Received by Date Receipt No. Permit No. ifsMance Date Mailed Delivered <br /> — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 3009 STOCKTON.CA 95201 <br />