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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICCUSE: ill, APPLICATION <br /> (For Non-Transferable,Revocable,Suspendeble) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> MPLETE IN TRIPLICATE I'�' � "T"'W T IAUTY <br /> ¢_ (P_Z�1�E�wtL4Zw se�y 1 203^ 030-02 <br /> Ppiication is hereby madetothe San Joaquin Local Health Districtfora"per tonoristructahc/or installthework.herein described.This application is <br /> made in compliance with Sa Joaquin Coupty Ordinance No. 1862 and the'rules and regulations of the San Joaquin Local Health District. <br /> , Exact site Address /�✓NI/o, 5N G9l.Q�s2oei�' —3c� City/Town' <br /> Owners Namen VRQ!' Phone r <br /> Address / y 16.4-!R - .. City_Y� rs , <br /> Contractor's Name� BA�rvL/ 'q'„o,Fa�.rj - License p3 79 r— Business Phone' <br /> Contractor's Address gaUCAB; :Emergency Phone -.'101 _^ <br /> Is Certificate of Workman's Compensation Insurance ol File With SJLHD7 Yes A— No j <br /> 1 TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 -DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ -OTHER Cl PUMP INSTALLATION ❑ PUMP REPAIRM r <br /> REPLACEMENT❑ <br /> F <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 /> 2.IRRIGATION _ IJ GRAVEL PACK Depth of Grout Seai <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - <br /> '❑DISPOSAL ❑ OTHER Other Information <br /> �. ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor N�/,lr eFl. l <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done t <br /> PR RUCTION <br /> State Work Done r NG A44 d <br /> TRUC710N OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ' E <br /> F. <br /> . I hereby certify that I have prepared this application and that the work will be done in aacprdance with San Joaquin County <br /> ordinances;state laws,and rules and regulations of the San Joaquin Local Health District. i <br /> Homeowner orlicensed agent's signature certifies the following:"I certify that in the performance of the workfor which this permit <br /> is Issued, I shall not employ any person-in such manner as to become subject to workman's compensationI}ws of California." <br /> Contractees hiring or sub-contraclidg Signature Certifies the following:"I certify that in the performance of th2ork forwhich this , <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.'! <br /> .,, 1 VI call for a Grout Inspection-orrior o dutin nd a ialinspedion. <br /> Signed XA f ) ✓=X . :Date: <br /> < (Draw Plot PI on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �'! (r��\ r,/�N�,, _ Q O' 1 <br /> Application Accepted By` j�• rel-��✓��-i A✓�- 0. 06- Date u `/� 6 I <br /> Additional Comments: - <br /> Phase 11 Grout Inspection es}r III F 9 <br /> Inspection By - I Date Inspection B <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J 1 6 Receive0 4&ancery 31 ❑July 1 a ReCelYed By July 31 <br /> REMIT <br /> BILLING REMITTANCE.. $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED - <br /> OATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY .. <br /> i <br /> OTHER .. ._. <br /> OTHER - - <br /> ia � <br /> R2Celved Ey Date Receipt No, Permit No. :_ Iss nce Da _ Wi1w .Delivered' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA TON AVE,P.O.Box 1009 STOCKTON,CA 96101 <br />