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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .FOR OFFICE LISE-1 APPLICATION <br /> Non-Transferable, Revocable,Suspendable) I/ PUMP&WELL <br /> ENVI901NMENTAL HEALTH PERMIT <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 Span Joaquin County Ordinance No. 1862 and the rules and regulation$of the San Joaquin Local Health District. <br /> Exact Site Address Z..( C.J< �� - Cityjown <br /> Owner's Name �7t�M�-1.�8 •>;� �f^�C.d_A�y�- �• Phone <br /> Address / y ? �� -37 City _ <br /> Contractors Name _ License """'4+ Business Phone $3_S— &' ) <br /> Contractors AddressEmergency Phone f/1 <br /> Is Certificate of Workg's ompensation Insurance on File With SJLHD7 Yes �� No <br /> TYPE OF WORK (CH CK): NEW WELL 13 DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION Q--�PUMP REPAIR❑ 0 <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 Well Public Domestic Well r <br /> INTENDED USE TYPE OF WELL <br /> ❑ IN TRIAL 13CABLE TOOL Die. of Well Excavation -41 <br /> STIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 0 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ' >� c_ Surface Seal LInstalled By: <br /> oni <br /> PUMP INSTALLATION: GractorT <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 Local Health District. Q <br /> Home owner or licensed agent's offirp{ ture 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 lchlhis <br /> permit is issued. I shall employ persons subject to workman's compensation laws of California.". <br /> I W1W-q&4qr a Grout Lnspeption prior to grouting and a final Inspection. . <br /> Signe ter+ w Title: T&4d-g Date: ce —/g <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /� `/� •7/�� <br /> Application Accepted By /�/� `L, Dale <br /> Additional Comments: <br /> Phase II Grout Inspection Pha I nal Inspection <br /> Inspection By Date Inspection By ^'Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE '❑ EACH ❑ January 1 d Received By January 3111 ❑ July 1 A Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE T q S <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I (-7 <br /> Received by Date Receipt No. Penn No. Ittsuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95201 <br />