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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ff <br /> FOR OFFICE USE: - APPLICATION <br /> . Non-Transferable,Revocable, Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to coAstruct and/or install the work herein described.This application is <br /> made in compliance with�S{gn J apu/iin County Ordinan Flo. 1862 antl flys rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /–f' lL" (:�.�. .dam- -�£- City/Town - <br /> 4 � <br /> Owner's Name �� ' ¢ Phone S 6 —U <br /> Address City /�L-�'�-+— <br /> Contractor's Name License g L Business Phdn <br /> Contractors Address 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 Fly PUMP REPAIR❑ <br /> REPLACEMENT❑ _ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> a <br /> Sewage Disposal Field Cesspool/Seepage Pit Other t <br /> Property Line Private Domestic Well T— Public Domestic Well <br /> INTENDED USE - 1 TYPE OF WELL �1 <br /> fSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> ❑ IyB1 <br /> DOMESTIC/PRIVATE ❑ DRILLED, " Die. of Well Casing ' <br /> ❑ DOMESTIC/PUBLIC. b DRIVEN Gauge of Casing <br /> ❑ IRRIGATION _ ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal I taped By: <br /> PUMP INSTALLATION: Contractor ).(O✓�.8.4� "MI d V <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: O'State Work Done' R •� <br /> PUMP REPAIR: ❑ Slate Work Done~ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and{,rocedure - <br /> I hereby certify that I have prepared this application and trot the work will be done in.accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the Sall.Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:-"I certitythat in the performapce 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•conlracting signature certifies the following:"I certitythat 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�e1Wy14lo&Grout Inspect!9n prior to grouting and a final Inspection. <br /> /C r <br /> Signed ie/ Title: z�.d'['y�2^ Date: —1— <br /> (Draw Plot Plen on Reverse Side) <br /> FOR DEPARTMENT USE ONLY, <br /> PHASE 1 DatB <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pha in Inspection <br /> Inspection By Date InspectioDate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January/a Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCEf <br /> BASE EXPLANgT10N DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ' AMOUNT <br /> ^ p_ f c C1J . <br /> FEE <br /> LESS T <br /> PRORATION r. / <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> D <br /> 15-9 <br /> Received by Date Receipt No. - Permit No. Inua.ce Date Mailod Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON,CA 95]01 <br />