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Applications Will Be Processed When SubmitfiCA Properly Completed. Be Sure To Sign The Application. E <br /> FOR OFFICE-USE:.." l APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site.Address 4 '� v-_4✓ LA J ek I City/Town 4 <br /> Owner's Name �- �'J dYt�!' Z` Phone <br /> Address City— CS <br /> Contractor's Nametx t License# J93 73 f�f�Business Phone <br /> Contractor's Address Emergency Phone Do <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes X No 0 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 1f PUMP REPAIR❑ <br /> REPLACEMENT❑ p <br /> DISTANCE TO NEAREST: Septic Tank 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 ., 1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> 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 Installed By: <br /> PUMP INSTALLATION: Contractor s \\� <br /> Type of Pump H.P. +� <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 /> Homeowner 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 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 call for a Grout inspectioruriort0 iing and a final inspection. <br /> Signed Title: 6.r Date: <br /> (Draw Pio Ian on Reverse Side) I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE (, <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT- ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BIL 9 <br /> REMITTANCE $ REMIT <br /> 'BASE EXPLANATION D PATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE C}� "�,I� d 0 <br /> LESS <br /> PRORATION 9 <br /> PLUS r� <br /> PENALTY ijVy <br /> i <br /> OTHER A J <br /> is <br /> OTHER <br /> 5k0 L�S� //_s€c� <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />