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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> FOR OFFICE usE: <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> -'-' WATER QUALITY 4 <br /> (COMPLETE IN TRIPLICATE)i'"�F(�,Q-6oK�Cr �"✓ — "' ;F <br /> Application is hereby made to the San Joaquin Local Health Dist tforapermittoconstructand/or instaNtheworkhereindescribed:Thisappkicationis <br /> made in compliance w h.San Joaquin County Ordinance No. 186aa th ryl�e reguj�igos of the San Joaq LocalHealth �Istrict. 4 <br /> Exact Site Address -346UJ? `jamGl "`•ity/Town <br /> Owner's Name :" �� � T _�' Phohe 5 `UC �?,�A <br /> Address 1� �/: /�l"r �- City �� � <br /> Contractor's Name ? �14 V* 00/ � �c��� Business Phone <br /> Contractor's Address 30 5 /1 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL❑` DEEPEN 13 - RECONDITION❑ - DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT L'1 OTHER ❑ PUMP INSTALLATION❑ . PUMP REPAIR❑ <br /> REPLACEMENT❑ Y <br /> U a� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines „ " Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domesticell Public Domestic Well 1 <br /> INTENDED USE TYPE OF WELOFLj[ ehc <br /> ❑ INDUSTRIAL 11 CABLE TOOL } Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ 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 <br /> l <br /> ❑ <br /> DISPOSAL ❑ OTHER ' Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ' <br /> { <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ❑ State Work Done _ <br /> PUMP REPLACEMENT: 1 �' <br /> UMP REPAIR: ❑ State Work Done <br /> ' Appro i Dept <br /> JESTRUCTION OF WELL: ell Diameter <br /> f s ' -Material and.Pr cedure O a <br /> G 1 hereby certify that I have prepared this application and t at thew 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 for which this permit <br /> j 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." _ <br /> I will calr Grout. spection rior to grouting and a final inspection. <br /> I Sig d Title: Date: <br /> � 6 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 0 -1�^ <br /> Application Accepted By Date <br /> Additional Comments: 7i <br /> Phase II Grout Inspection Phase I I Final Inspection <br /> Inspection By Date Inspection By o ate <br /> -Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ElEACH '❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 may_ <br /> REMIT <br /> BASE EXPLANATION- BILLING REMITTANCE_; $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE D <br /> LESS <br /> PRORATION - f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER .. <br /> Received by te. Receipt No. Permit No. - _ Issuance Dale_ Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />