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T <br /> I Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: E APPLICATION Loi /l J <br /> { �=--- <br /> :or Non-Transferable,Revocable,Suapendable, .,ID <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL t <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 w/it-h San J/oAquin County Ordinance No. 1862 ag t e rules and re ul�F/o s of the San Joaqui Local Health District. <br /> Exact Site Address .n r�>f'�I(C7 �� Mn 1i/1�4�: �QQi Q - ,�•�j� �y(`� fy?own <br /> nn ;^ + <br /> Owner's Name ,(YC9C, '4/,c�'1(_� ' � Phone � <br /> Address L <br /> City � <br /> Contractors Name ! • s" /�'�Licensli a .99O�/�3 Business Phone <br /> Contractor's Address 13 P•.T`-tIAC&a�., Emergency Phone 5VS-pa 7/ <br /> Is Certificate of Workman's Compensation Inst nce on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL IF DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ . OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /06 Sewer Lines Pit Privy <br /> Sewage Disposal Field /00" Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE - TYPE OF WELL <br /> �❑( INDUSTRIAL Q CABLE TOOL Dia. of Well Excavation 8 <br /> X DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 16.4 Pt/7. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing )a= <br /> 0 IRRIGATION ��}I'GRAVEL PACK Depth of Grout Seal 741 <br /> ❑ CATHODIC PROTECTION I ROTARY Type of Grout <br /> ❑ DISPOSAL - ❑ OTHER Other Information �Q6 —`q 37,1 qq <br /> ❑ GEOPHYSICAL T— Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ staje 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:"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 /> Contractors 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 Grout Inspe tion prior to grouting and a l�spection. <br /> Signed X ^ ���777 I /�J/ �3 <br /> -c,.,��.�"��/ Dater S 7 <br /> (Draw Plot Plah'on Ravi Side) <br /> FOR D ARTME -T USE ONLY <br /> PHASE <br /> Application Accepted By ^�^ Date 0 / <br /> Additional Comments: 4 V4 <br /> Phase II Grout Inspection he III Final Inspection <br /> Inspection By Date �r�spectloD By to I I <br /> Fee Is Due: ❑ ANNUALLY D PER UNIT PER SITE ❑ EAC ❑ January 1 a R eived January July t a Received By July 71 <br /> BILLING REMITTANCE $ REMIT <br /> 'BASE EXPLANATION' DATE DATE 'REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS [/ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I A <br /> OTHER <br /> c7 I S1117 <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE..P.O.So.2009 STOCKTON,CA 25201 <br />