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. qt- rM F Appllcalicns Will Be Pro eased When Submitteri Property Completeb Be Sura To Sign The Application. <br /> - <br /> =FO APPLICATION <br /> {�y1�o�o <br /> l� (For Non-Transferable,Revocable,Suspendable) PUMP WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY i <br /> Al:3piicatioRisherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstallthework herein described.This application is <br /> made in compliance with San Joa alit Count Ordina�nc�r No.1862 and the rtes an regulations of the San Joaquin al Health District. <br /> p —�� '� / Q Y, ' WCL- -City/Town <br /> Exact Site Address_ <br /> ti -Owner's Name /4 m �� _ _ Phone16L C <br /> Address �'' a:J - C'ty <br /> 9y-1 Business Phone <br /> Contractor's Nam — License fli F <br /> Contractor's Address -a Z Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fi With SJLHD? Yes �� No -_ <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN 13RECONDITION 13 DESTRUCTION❑ <br /> -' WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> iS <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 Weil. Public Domestic Well___-_-_"__ ---------- -� <br /> INTENDEC USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation---------------------- <br /> DOMESTIC/PRIVATE <br /> xcavation ------------------DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> /` ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing — -- -- <br /> l <br /> "� ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> " ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - <br /> .;i <br /> 4; ❑ CIISPOSAL ❑ OTHER_____--- Other Information - — --- <br /> Y ❑ GEOPHYSICAL Surface Seai Inst tied By:_ --- <br /> 1+ , A <br /> PUMP INSTALLATION: Contractor- ?�u) r� - <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 LCcal Health District. <br /> Homeowner or licensed agent's signature certifies the following: 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." a. <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 <br /> -cah for a Gioul Inspection prior o frau ng" d a final inspection. <br /> Signed X�Ilfy� rA e: a/ - Date:­-,,2A� /�,2 <br /> (Draw Plot P on Reverse Side) <br /> /J FOR DE ARTMENT SE ONLf <br /> PHASE I /l��= <br /> Date <br /> Application Accepted By-- <br /> Additional Comments: <br /> Phase II Grout Inspection p�ha 111 7^/al In.{spection ^/O_ 1) <br /> inspection By._- -- --- Date <br /> --- <br /> ---- Inspection By�! �/— Date <br /> Fee Is Due:❑ ANNUALLY El PER UNIT PER SITE ❑ EACH ❑ January 1 8 Fler— cerveU BY January 31 ❑July''8 Reaely FEMIT July 31 i <br /> �!. BASE EXPLANATION T BILLING REMITTANCE S AMOUNT DUE CHECKED 1 <br /> DATE DATE REMITTED AMOUNr <br /> FEE �_��_ -- ' ---- <br /> I <br /> LESS <br /> PRORATION <br /> I' <br /> PLUS <br /> PENALTYAi,_-_ -- -- —' <br /> OTHER r — <br /> I <br /> OTHER / /. /d }�- f i -7 -- ,- <br /> - <br /> LJ-e �y <br /> Chin✓/ o- Cit J f_ --1=-A.Q <br /> _ <br /> Date- 9,,r N a- `O Permit No Issuance Date Maded Delwerea <br /> Recewed Dy <br /> �/+ APPLICANT—RETURN ALL COPIES TO: EN' ENT9"EALTH PERMIT/SERVICES 1601 E.HAZELTON< 0.Boa 2009 STOCKTON,CA 95201 — <br />