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Z Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION • 2� <br /> or Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP &WELL <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 wit <br /> `h�San <br /> �Joe Jin County Ordin nce o. 1662 and the�(ules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address IS,CCa�_Lc ll��D/�/ t aixifa.,1/ iTsA L/.� 9 l <br /> City/Town ALE OOiI I�IGL�t l <br /> Owner's Name Phone <br /> Address <br /> City �rl�D rx <br /> Contractor's Name . license p 029a&3 Business Phone_ <br /> Contractor's Address �3SaS QvGos•�¢/oma `�'yJ., Oa�.n Aargency Phone <br /> Is Certificate of Workman's CompensationIns ranee on File With SJLI Yes X No d <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> r <br /> DISTANCE TO NEAREST: Septic Tank —_fL� SaweLines Pit Privy <br /> Sewage Disposal Field /�IF., ; 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 iii ��iC7(/G <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1606ya 4 .1 <br /> ❑ IRRIGATION XGRAVEL PACK Depth of Grout Seal Ia <br /> ❑ CATHODIC PROTECTION 9 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALSurface 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 N <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:"I 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 /> Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for wh ich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Ins n prior to grouting and a final inspection. <br /> Signed X 1.�..-,; -- Title: 91Z.31 <br /> Date: <br /> If (Dra Plot Plan on Reverse!Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �/ Q1 <br /> Application Accepted Bvp! !F/r// L Date o�y-LT14 <br /> Additional Comments:_{=, <br /> ,hall�e I Grout Inspection 1 Phase III Final Inspection <br /> Inspection By �1J/�!- Date 157'1— , .-,� Inspection By Date nLv <br /> Fee Is Dae: 13 ANNUALLY ❑ PER UNIT 13 [2 PER SITE EACH ❑ January 1 L Received By January 31 ❑ July 1&Receivad By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> (� DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHE <br /> 4�sa'/ 8 8' f ►3aoc� <br /> ceivetl Dy Date Receipt No. Permit No. Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa ZOOe STOCKTON,CA sa"I <br />