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npynwuuna nm oc rrwcaacu nota a muuwu rrupmry a..min.ueu.Oe auty to atgn ane eippucation. <br /> FOR OFFICE USE: YAPPLICATION <br /> or 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 for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with S n Joaquin CoouunctI Ordinance No. 1862 and the rules and regulations of the San Jo in Loc I, Ith District. <br /> Exact Site Addres 0�� S+ L ! y -I+� City/Town� �'t_. <br /> Owner's N e Phone `� <br /> Address j City <br /> Contractor's Name License#, ,� Business Phone n �h <br /> Contractors Address h�m T�LP�-^�++-� Emergency Phone `fe`t�G7 �/ l <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❑ <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 /> ❑ 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 Su ace SeaInstalled By: <br /> l r <br /> PUMP INSTALLATION: Contractor�!�Lk` X;,� . i l .9 <br /> Type of Pump H.P. <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 /> 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 owneror licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich thispermit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Of <br /> Contractor's hiring or subcontracting signature certifies 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 /> RI f for a out Ins a lfo for to grou ng and a final inslpeccttdn. <br /> Sig Tiller�7i'XibLc-tr /Hi� Date: d 7 <br /> (Draw Plot Plan on Fleverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By - "' 'h"®� Date <br /> Additional Comments: <br /> Phase II Grout Inspectiona a 111 Final Ins ction <br /> Inspection By �I_L� Date Inspection By l i ate lU �Z- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I&Received By January ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT _ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. laftuanc.Data Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.SPK 20119 STOCKTON,CA 95201 <br />