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Applications Will Be Processed When Submitted Properly Comp d 4yl*' r)6o igA The Ap ion. <br /> FOR OFFICE-USE: APPLICATION <br /> (For Non-Transferable, Revocable, ndabl PUMP&WELL <br /> 11 <br /> ENVIRONMENTAL HEALTH PERMIT" I it �_C)CW � <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY AN [�4 � iC <br /> Application is hereby made tothe San Joaquin Local Health District for apermit toconstruct and rlOstj31i�f1tsVvOR'.herein described.This application is <br /> made in compliance wi�h San Joaquin County Ori ante1862 and the rules and regulations the San Jga�tuin Local Health District. i <br /> Exact Site Address Cit /Town C'd1_ eL- kr.1 <br /> Owner's Name-t Phone Q <br /> Address _z City Nze At `I`e ca <br /> Contractor's Name License#;�-. Business Phone e <br /> Contractor's Address Emergency Phone [ t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes � No <br /> TYPE OF WORK (CHECK): NEW WELLJK DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> ( i <br /> DISTANCE TO NEAREST: Septic Tank .0® `f' Sewer Lines 1 Pit Privy <br /> Sewage Disposal Field l/ 't Cesspool/Seepage Pit Other f <br /> Property Lined Private Domestic Well� �7� Public Domestic Well 'I <br /> INTENDED USE TYPE OF WELL pf <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 14 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout u <br /> ❑ DISPOSAL ❑ OTHER Other Information ` <br /> ❑ GEOPHYSICAL -� ; Surface Seal Installed By:, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. S <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. ; <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 fallowing:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall emplo persons subject to workman's compensation laws of California." <br /> I <br /> ill r a Gr I on p • to grouting and a final insp do <br /> Signed X Title Date j <br /> (Draw Plot Plan on Reverse Si ) <br /> • I <br /> FO DEPARTMENT USE ONLY <br /> PHASE 410�z <br />' Application Accepted By <br /> Data1/, �o� <br /> Additional Comments: <br /> P se H Grout Inspection /Ph s Ili Final Inspection <br /> Inspection By Date_ 6 l s5`� Inspection By ` Date <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &:'Received By Juiy 31 <br /> $ <br /> REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMDUNT DUE CHECKED ;! <br /> l DATE DATE REMITTED .,AMOUNT <br /> t <br /> FEE <br /> LESS <br /> PRORATION <br /> • PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6q '31-6 -� b <br /> t Received by Date Receipt No. Permit No IssuAnce bate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />