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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) ISS WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstruct and/or install the Ork herein described.This application is <br /> made in compliance wt San Jo quip 1 y Ordin�a�n//ce N . 1 2/alld the r s n regal dro I�t��/tgh�J r Joaquin cal HCa th D trict. <br /> Exact Site Address\ M. Cr —zselo7�,Q L Q�IC�j� ttj <br /> Owner's Name -le _ (�. !7—,� _ `P/Ihone, 362- 77/0( <br /> Address /. Qom_ /� ^ Cz tip _.-- City <br /> Contractor's Name -�> y�`�117J License 1►�f0-9/,,? Business Phone 5215-' <br /> Contractor's Address ,Sa� Q�a�(�Ctl C75�DEmergency Phone <br /> Is Certificate of Workntan's Compensation Insurance on File With SJLHD? Yes b-11 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 Line; _ 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 p ,. <br /> INDUSTRIAL ❑ CABLF TOOL Dia. of Well Excavation _ cX _ <br /> ❑ DOMESTIC;PRIVATE ❑ DRILLED Dia. of Well Casing /fes <br /> ❑ DOMESTIC/PUBLIC ❑ RIVEN Gauge of Casing <br /> VRRIGATION RAVEL PACK Depth of Grout Seal LI <br /> ❑ <br /> CATHODIC PROTECTION 1440 T A R Y Type of Grout f1Pn`U _-i <br /> ❑ DISPOSAL ❑ OTHER Other Information Z �ZlZZ � <br /> ❑ GEOPHYSICAL Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor _ <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 owner or licensed agent's signature certifies the following:1 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 /> Contractors hiring or sub-contracting signature certifies the following:"I certtfy that in the performance of the work forwhich this <br /> permit is Issued, I shall employ persons subject :o workman's compensation laws of California." <br /> Iaaw�'1 call fora Grout ectlon prio fo groyting a final inspection, <br /> Signed X rAL ` _� - C J J� `` <br /> _ Date: <br /> Draw Plot Plan on Reverse S t <br /> ( do <br /> r r2 LL:c (� No QEF FOR EPARTWNT USE ONLY <br /> PHASE � <br /> Application Accepted By _�� Date <br /> —. -- — — <br /> Additional Comments: <br /> Phase 11 Grout Inspection hase II Final Inspection <br /> Inspection Bye" D:at; Inspection By 17at? <br /> t � <br /> Fee Is Due: ❑ AIINUALLY (] PER UNIT IN 'FF;5i T L ❑ LACH ❑ January 1 8 5y January 3' ❑ ,h,'y t d necerved E1y. . <br /> —_ R EMI T—_ <br /> !:ASL DATE DATE REMITTFn <br /> EXPLANATION 13lNG RF_ Tgp,1,F AMOUNT DUE CHECKED <br /> D <br /> AMOUNT <br /> FEE G 1 f <br /> LESS I f <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _C J_ <br /> Ruu,invra by Date ROGO.61 No r­m;Nu- Issua ce L1ate ' Man,:,7 n�hven+d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E-HAZELTON AVE.,P.O.Boi 2009 STOCKTON.CA 115401 <br />