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Applications,jy ilf se F04eyso When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> t I <br /> -No -Transferable, Revocable, Suspendable) PUMP&WELL <br /> GAIJ <br /> dr HAL!H:� DIST IEA IRONMENTAL HEALTHPERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance withSlaCt Joaquin County Ordinance No. 1862 and he rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �1 rM� L 4 A e City/Town' <br /> Owner's Name 1*I� Phone <br /> 'City '` -. <br /> Address <br /> Contractor's Namea S,� % S�'Sr�F+��I` License# _%ze- Business Phone . `?!ZZJ <br /> Contractor's Address 945 0wA1' 'yS�• ''` �' _ . ` Emergency Phone <br /> Is Certificate of Workman's CompensationInsurance on File With SJLHD? Yes No Vv <br /> L 13DEEPEN © RECONDITION❑ DESTRUCTION <br /> TYPE OF WORK (CHECK): NEW WEL ❑ <br /> WELL CHLORINATION ❑ WELL ABf NDONMENT ❑ 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 /> INTENDED USE TYPE OF WELL, - <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 91 DOMESTIC/PRIVATE I❑ DRILLED r 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 /> ❑ DISPOSAL- - ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL k [ SurfaceSeal Installed By: <br /> PUMP INSTALLATION:. Contractor <J i ? Zr <br /> �z- <br /> Type of Pump f H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: !❑ State Work Done ) <br /> DESTRUCTION OF WELL: I Well Diameter t Approximate Depth <br /> Describe Material and Procedure Q} <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 for which this permit <br /> is issued,-1 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, 1 shall employ persons subject to workman's compensation laws of California." <br /> i f <br /> I all far a Grout nspectio prior to grouting and a final inspect# a - <br /> Signed X Title: f Date: y� <br /> -'1 R v rse Side <br /> I� (Draw Plot Plan on e ) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted �r t Date <br /> Additional Comments: 1p. <br /> Phas I Grout Inspection ; ,.4 Pha a III Final Inspection <br /> Inspection By k Date 4J Inspection'By Date <br /> I� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE 'I EXPLANATION BILLING REMITTANCE 4 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 5P <br /> PRORATION �. <br /> PLUS �p <br /> PENALTY <br /> OTHER <br /> OTHER II <br /> rY1DL1 b�� <br /> Received by Date—1 11 Receipt No, Permit No 'Issuance Date Mailed Delivered - - <br /> APPLICANT—RETURN ALL COPIES TO: I ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />