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ApplicationsWill Be Processed VJnon$uhmlUed Proparlq Completed. Bo ciao To Sign The Application. r <br /> FOR OFFICE USE:' ,..' .; " . APPLICATION <br /> (For Non-Transferable, Revocable(Suspendabl� ,. PUMP&WELL Z� <br /> _ J <br /> ENVIRONMENTAL HEALTH PEAMIT <br /> �o I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> i <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made In compliance with San Joaquin County Ordinance No. 1862 And tho�Yulos And rogulnllons of Iho Snn-''JJ1onquln LocniMonith District, <br /> CXact Site Address�Q��� S - ���o blynown <br /> Owner's Nem � � � �!•.,, ��, Phone • Q�z–Z <br /> Address` •r`'� _ •'� City �� -r <br /> C'ontractor's Name Oi _'. � L I c e n s a N3 �( Business Phone' <br /> Contractor's Address -� —(—�`�-�z1-2,.. Emergency Phone <br /> 1 <br /> 1^ Certificate o1 Workman's Comperisatlon.lnsurence on File With SJLHD7 '.:Yes—.— No (� <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q <br /> VJELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION D—PUMP REPAIR❑ ..y <br /> f1EPLACEMENT0 <br /> CISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Ci <br /> Properly Line Private Domestic Well Public Domestic Well - -� <br /> INTENDED USE TYPE OF WELL •C <br /> ❑ It TRIAL ❑ CABLE TOOL Die. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Die. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN . Gauge,of Casing <br /> ❑ IRRIGATION - ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ <br /> CATHODIC PROTECTION ❑ ROTARY _ .. .Type of Grout ' <br /> DISPOSAL ❑ OTHER .Other Information <br /> C7 GEOPHYSICAL ' Z' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor–I � ^– <br /> Type of Pump . H.P._( <br /> PUMP REPLACEMENT: 11 State Work Don <br /> PUMP REPAIR:': ❑ State Work Done <br /> CESTRUCTION OF WELL: Well Dlameter Approximate Depth <br /> .. Describe Material and Procedure <br /> fi <br /> I hereby.certify that I have prepared this application and that the work will be done In accordance with Son Jonquln 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 performanceof the work forwhich this permit y <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." `tlt- <br /> Contractor's hiring or subcontracting 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 c to Grout lnspec Ion prior to grouting and a final Inspection. <br /> Signed X _ Title: Date: -(e--L9 <br /> (Draw Plot Plan on Reverse Side) <br /> .FORD PARTMENT USE ONLY <br /> PHASE A ' <br /> Application Accepted By !�gy �/Gr�-�� Datey <br /> Additional Comments: <br /> Phase II Grout Inspection Ph IU nal Inspections <br /> Inspection By Date Inspection By / Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jonuory 1 &neceived By Jo nun I CO July 1 A Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> �5 <br /> LESS <br /> PRORATION . <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Roceivo0 by Dele noc0ipl N0. Permit No. leeunnco Onto' Mniled Dnlivnrc0 <br /> .L_ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMITISEnvices 1001 E.HAI,ELTON AVE.,P.O.Go,2009 STOCKTON.CA 95201 <br />