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►►*i • Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> FOR,-OFFICE-USE: <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL _ <br /> ENVIRONMENTAL HEALTH'PERMIT ?`�(97 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY. <br /> Application is hereby madetothe San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made incompliance with San.Joaquin..County Ordinance No.-1862 and the rules and regulations of the San Joaquin Local Health District. <br /> 4016 Hubbard Rd City/Town` Stockton <br /> Exact Site Address <br /> Owner's Name .. -.-Ernie schi=0 Phone 931— 6_�X7 <br /> Address same City' <br /> Contractor's Name MOOrmc'2nr S 'Nater" S stcmS 'License#267696 Business Phone 931-321.0 <br /> Contractor's Address �2 20 Wi1COX Rd " " °' - Emergency Phone y t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELLOC -DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑^--OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ C<t <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank e-'ewer Lines Pit Privy <br /> Sewage Disp1' 6eld 4— Ces pool/Seepage Pit _ ` � Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL' <br /> ❑ II DUSTRIAL f ❑ CABLE TOOL' -Dia. of,Well Excavation 1263 <br /> DOMESTIC/PRIVATE �❑�,,,, DRILLED Dia. of Well Casing r1 <br /> [IDOMESTIC/PUBLIC l£t'DRIVEN Gauge of Casing <br /> ❑ IRRIGATIONI. �� <br /> El GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By," <br /> ❑ GEOPHYSICAL; <br /> I Moormants Water Systems <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ -r�'f! H.P. <br /> PUMP REPLACEMENT: ❑•State Work Done r <br /> PUMP REPAIR: 1 ❑ Stl <br /> ate Work Done Q <br /> DESTRUCTION OF.WELL: Well Diameter App��oximate Depth <br /> f <br /> rocedure ,r <br /> t Describ Ma rial and P <br /> L'] <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 forwhich this permit <br /> is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> l 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,'I shall employ persons subject to workman's compensation laws of.California." <br /> I will call for a Groul Inspection prior to grouting and a final Inspection. # pp <br /> + � Date: <br /> Signed X Title:.. <br /> f (Draw Plot Plan pn Reverse Side) <br /> FOR DEPARTMENT USE ONLY pp <br /> PHASE I <br /> Application Accepted By Dake <br /> Additional Comments: <br /> ` Ph se I Grout Inspection P se I Fina spection <br /> - Inspection By l Date inspection By - Date <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received'By January 31 ❑ July 1 &Received By Ju4y 31. <br /> [[ REMIT <br /> 3 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - DATE DATE REMITTED AMOUNT <br /> FEE4u 06 <br /> i LESS ' - •{ <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER � q <br /> OTHER ' �.c7(J <br /> F ! <br /> Receipt No. Permit.No. 195 ance D e Mail edDelivered, . <br /> ° APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 ST.00KTON,CA 95201 <br /> f <br />