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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) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 4 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 1 <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described,This application is <br /> made in compliance with San Joaquin County Ord'Lnance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address b City/Town <br /> LL � <br /> Owner's Name 4._T d COW- Phone <br /> Address _ City <br /> //* License# Business Phone I`r <br /> Contractor's Name [ _ <br /> Contractor's Address _ `_�` Emergency Phone I{6� <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No f <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION(, o�+ <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 /> INTENDED USE TYPE OF WELL 111 { <br /> kNDUSTRIAL f 11CABLE TOOL Dia. of Well Excavation , <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing D <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION ❑\ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 L: Well Diameter App ro imate Depth 1 } <br /> Descri a Material and Procedu e <br /> I hereby certify that I have prepared this application d that t e 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:"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 i <br /> per it is issued, I shall employ persons subject to workman's compensation laws of California.' <br /> d <br /> 1 MI all for a o .Ins io rior to grouting and a final inspection. <br /> Signed X : Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7, /-0 l <br /> Application Accepted By ` Date <br /> Additional Comments: <br /> Phase III Final Inspection <br /> CJ <br /> P e I Grout Inspection <br /> Inspection By Date Inspection By Date a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑'EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING 4RFMITTAN4CEZAMOUNTDUE CHECKED <br /> DATEk$ L <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br />` OTHER <br /> F OTHER <br /> 1 <br /> I ;L�00 -s'1,�_s -S 1 <br /> Received by Date Receipt No. Permit No. I nuance ate Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.O.Bok 2009 STOCKTON,CA 95201 <br />