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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OKF,�CE USE: APPLICATION <br /> " (For Non-Transferable, Revocable,Suspendable) PUMP&WELL f °� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) .;,WATER QUALITY <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 w t San JoaquC <br /> ' ` ourtty Or n ge No. 1862 d he rules and regulations-of the San Joaquin Local Health District. ' <br /> Exact Site AddressCity/Town ; s <br /> ~/ <br /> Owner's Name l�+ 1 Phone y '� <br /> Address '" ° { City' <br /> Contractor's Name E R _ License ot '�"��.�Business Phone 1 <br /> Contractor's Addr� Emergency Phone <br /> I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): ' NEW WELL t' DEEPEN ❑ RECONDITION❑ '-DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank /�GZ,, Sewer Lines IAJ h Pit Privy d"4,, T_ <br /> - Sewage Disposal Field - Cesspool/Seepage Pit Other <br /> Property Line . . Private Domestic Well Public Domestic Well _ <br /> INTENDED USE TYPE OF WELL <br /> e: ❑ INDUSTRIAL R-CABLE TOOL Dia- of Well Excavation <br /> i ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia- of Well Casing �9+� <br /> ❑ DO C/PUBLIC ❑ DRIVEN Gauge of Casing Y <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> PROTECTION _ ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 0 OTHER ; Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By:: <br /> PUMP INSTALLATION: Contracto r <br /> Type-of Pump ;L;-lel H.P- <br /> � vA <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 foilowing:"I certify that in the performance of the work for which 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 Inspection prior to grouting-and a final inspection. <br /> S74y J x. 1 <br /> Signed ' Title:. <br /> Date: CF7,— <br /> (D4w Plot Plan on Reverse Side) -- -� -- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ° <br /> L Application Accepted B 0 D to <br /> Additional Comments: ' Q�I EJ h y u <br /> Phase 11 G o t spection ha II Final Inspection <br /> Inspection By Date Inspection By Date ' <br /> Feeds Due: © ANNUALLY El ER UNIT ❑'PER SITE ❑ EACH ❑ January 1 t£Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT <br /> FEE' <br /> LESS- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by _-_ Date Receipt No. Permit No. - -Is uan Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />