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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. f <br /> FOR OFFICE USE: APPLICATION a Z <br /> Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER,QUALITY <br /> Application is hereby made to the Sao Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is 9 <br /> made in compliance with San Joa uin�u.m, y Ordin nce No 1862 and th rut sand reg sof the San Joaquin Local Health District. -� <br /> Exact Site Address Art �.Z -l3� QP� . — A,/� Gid xty/Town <br /> VV <br /> Owner's Name Phone <br /> Address City 2 �� <br /> Contractor's Name QJS License If 0 713 Business Phone <br /> Contractor's Addr( gency Phone 21 Ln, <br /> Is Certificate of Workman's Compensationn urance on File With SJLHD9 Yes, — No (� <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ ' OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank NO 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 /> 11INDUSTRIAL _ ❑ CABLE TOOL Dia.of Well Excavation /t/ <br /> A4 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ��y l <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 16 etA2" <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout,Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information_L — <br /> ❑ GEOPHYSICAL Surface Seal Installed By: a'.1 44 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State_Work Done - I <br /> PUMP REPAIR: Q Stale 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. 4. <br /> Home owner or licensed agent's signature certifies the following:••1 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 wf call for a Grut 117 <br /> action ri1"or to grout g and a final inspection/') (, <br /> Signed X to <br /> v(%F�. Date: <br /> (Draw Plot Plan on Reverse Side) - J <br /> 1 <br /> FOR EPAR7 ENT USE ONLY <br /> PHASE I Application Accepted By ...•� d1 Date Q /-7/9 <br /> Additional Comments: <br /> Phase 11 Grout Insgg��• on hese III Final Inspection t)� <br /> Inspection By C k N fat ' /D 9 �_ Inspection By �J.n.. <br /> toLail uw%"r <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE Q EACH ❑ January 1 8 Received B1 ❑ July 1 A Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT � <br /> FEE y3 — <br /> LESS <br /> PRORATION ` <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER <br /> /15/79 <br /> dived Dy � Date ReceiPl No No. Permit No. Issuance ale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.9Av YOe9 STOCKTON.CA,95701 , <br /> N % ,T 7 <br />