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Applications Will Be Processed When Submitted Properly Completed.Be Sure To SignTheApplication <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) j PUMP&WELL <br /> r ENVIRONMENTAL HEALTH PERMIT r <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Hoalth District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance wit�l� Jo quin C my Ordinance No. 186 d the rules and regulations of the San Joaquin"Local Health District. <br /> Exact Site Address 0 d ���-r� City/Town <br /> Owner's Name A IVI A � Phone <br /> ^� <br /> I U U t .. City M 0101 t 3 Tr7 C <br /> Address ZR <br /> Contractor's Name �j�.E <br /> e r'C Business Phone <br /> Contractor's Address <br /> ~ u',> mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File_ With S' - , f Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ 1.., <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 5 Pit Privy �. <br /> Sewage Disposal Field Cesspool/Seepage Pit,' Ofher <br /> N Property Line Private Domestic Well rPublic Domestic WBN <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL . ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout C <br /> ❑ DISPOSAL ❑ OTHER Other Information _ r <br /> : r ? <br /> ❑ GEOPHYSICAL Surface Seal Instal By: %4 <br /> PUMP INSTALLATION: . .;, ` Contractor < <br /> Type of Pump ll1J H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done r <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth 1 <br /> ' DESTRUCTION OF WELL: Well Diameter. <br /> Describe Material and Procedure. <br /> 7 <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." r <br /> Contractor's 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." l <br /> I ill call fora G spectio prior to grouting and a final inspection.-' t l l € <br /> Signed X <br /> Title: 3 f� Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ift Date <br /> -.Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection P e RI al Inspection <br /> Inspection By Date Inspection By Date <br /> f._ <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH El January 1 &R- ived By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> DATE DATE. REMITTED AMOUNT <br /> FEE , <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> - i <br /> .OTHER " <br /> . /s46�3 <br /> ReOeived'by Dat - Receipt No. - Permit No- Issuance Date Mailed Delivered <br /> y ,, �APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HE0.4TH PERMITISERVICE5 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95261 - <br />