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T ti Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transterable, Revocable; Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY w <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a 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 10329 N. Childress City/Town to k , <br /> Owner's Name es'' hari onPhone 931-2167 <br /> city <br /> Address '''� - � <br /> Contractor's Name MdOrltldYl� sT Water m License# 6_� - Business Phone' 931-3210 <br /> l <br /> Contractor's Address 2120 Wilcox Rd: Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X <br /> No <br /> TYPE OF WORK {CHI=CK): NEW WELL El DEEPEN ❑ RECONDITION DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT[1 OTHER 13 PUMP INSTALLATION # PUMP REPAIR❑ ( n <br /> REPLACEMENT❑ �f <br /> s Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Line <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <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 ❑ GRAVEL PACK Depth of Grout Seal d <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> f ❑ DISPOSAL ❑ OTHER Other Information <br /> El GEOPHYSICAL Surface Seal Installed By: -, <br />' PUMP INSTALLATION: Contractor Moorman' s Water ' stems <br /> Type of Pump submiersible H.P. 1 2 <br /> PUMP REPLACEMENT: DCI State Work Done re lace existin umwith new <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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:"1 certify that in the performance of the work for which this permit <br /> 4 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 Inspection prior do grouting and a final inspection. <br /> Title: — Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Dated—`r <br /> Application Accepted By <br /> Additional Comments: <br /> P ell Gr 1 Inspection -Phase II'-Final Inspection <br /> Inspection By Date Inspection By Date <br /> c� / � �� <br /> Fee Is Due: ❑ ANNUALLY ❑ R UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Recely d By REMITuly 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 /> OTHER <br /> Received by <br /> Date Receipt No- Permit No. issuance D te= »= Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.aox 2009 STOCKTON,CA 9520 <br />