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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 3 <br /> Application is hereby madetotheSanJoaquin Local Health District fora permit to construct and/or install the work herein described.This application is__cN <br /> made in complianceSan Joagyjn County Ord in ce No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> r I � <br /> , <br /> Exact Site Address_ ©CD ._ �+,� City/Town <br /> Owner's Name +fit Phone <br /> Address If city' <br /> Contractor's Name License#&qG-%Q Business Phone $14730y.� <br /> Contractor's Address Emergency Phone <br /> 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLISI DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <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 /> i <br /> INTENDED USE TYPE OF WELL a6 <br /> 13 INDUSTRIAL C1 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION LSI GRAVEL PACK Depth of Grout Seal � JF <br /> ❑ CATHODIC PROTECTION 01 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information d <br /> ❑ GEOPHYSICAL_ Surface Seal Installed By: (r` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter bir rr Approx ate Depth <br /> DescribeMat rial and Procedure <br /> i <br /> r14F B <br /> iE I hereby certify that I have prepared this applicati and that the work will be done in ccordance with Sa Joaquin CounI§ <br /> i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> f 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 following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall empl per ns subject t workman's compensation laws of California." <br /> I will I for a Gro sp tion for to grout' g and a final inspecti n. <br /> Signed X Title: !� - -�-yt Date: o <br /> (Draw Plot Plan on Reverse Side) <br /> TFOREPART NT USE ONLY <br /> PHASEIApplication Accepted ByZ "' Date / <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 11 Final Ospection <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 /> REMIT <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 /> It <br /> 1 3 71 -�a <br /> I Received by Oate L Receipt Na. Permit No. - ls*ancA Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 '"' <br />