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^MY .cvra *� roc r-tvuveosu waren auumla[ea rropeny L;ompieted. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> !' (For Non-Transferable, Revocable,Suspendal le) /� <br /> — ENVIRONMENTAL HEALTH PERMIT PUMP&WELL / -� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY1 r� 1'�� JSO3 <br /> Application is hereby madetotheSanJoaquin Local Health District fora permit toconstruct and/orinstallthework herein described.This application is <br /> made in compliance with San Joaquin Cmy Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addres 1474 N. Nornton Rd. City/Town <br /> Owner's Name Phone s <br /> Address Y _ City— —y— fSr�Tl7 � <br /> Contractor's Name License#;�K4S­ Business Phone___?� �^' 1 <br /> Contractor's Address b Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 <br /> REPLACEMENT❑ 4 <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 s <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing g <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 4;_ <br /> 0 <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout ri —r _ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _ t`re K11no C_]'p y► <br /> PUMP INSTALLATION: Contractor ..tdJy ��i�G�rnc <br /> Type of Pump-- 1;.y"9 n -C-11 We- H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done J <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Insp on prior to grouting and a final Inspection. <br /> Signed X '� c — Title: Date: /9a, <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By 1 , Date <br /> Additional Comments: _ <br /> Phase 11 Grout Inspection �h se III Final Inspection <br /> Inspection By _ Cate Inspection By Date �✓ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received ByV-ar 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMI7TTED <br /> AMOUNT <br /> FEF <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ` <br /> Received by I Dale Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PE IT/SERVICES 1901 E.HAZELTON AVE.,P.O.Bort 2aos STOCKTON,CA 85201 <br />