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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> 4.o Id l' m (For Non-Transferable, Revocable, Suspendable) <br /> [ 1�. ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1$62 and t rLlles and regulations of the San Joaquin Local Health District. <br /> t Exact Site Address es 11 � City/Town <br /> Owner's Name fV Q-17 Phone <br /> Address City (� <br /> Contractor's Name License# /'3 72<.5 Business Phoney <br /> Contractor's Address a4 FR Emergency Phone <br /> al, <br /> Is Certificate of Workman's Compensation Insurance on File W' SJLHD? Yes �X Na <br /> r TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ ' DESTRUCTION❑ cam, <br /> } WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> " DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> r Se, age Disposal Field Cesspool/Seepage Pit _ Other. <br /> rt : <br /> Property Line Private Domestic Well Public Domestic Well 1 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 11 ❑ DRILLED" Dia. of'Well Casing ' <br /> t ❑ DOMESTIC/PUBLIC I El-DRIVEN Gauge of Casing. <br /> IRRIGATION —11 GRAVEL PACK Depth of Grout Seal M <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump v ./ <br /> PUMP REPLACEMENT: ❑ State Work Done k ' <br /> PUMP REPAIR: ® State Work Done a 11Le'4i k 14 42r o I <br /> DESTRUCTION OF WELL: ,I 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. t <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, 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> II il call for a Grout Ilnspectio =ifinjgd aFfi inspection: <br /> i Signed X L�' � 'Date: (� 6 <br /> l (Draw Plot P on Reverse Side) <br /> hh <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I l _ <br /> Application Accepted By (� e > d _ dZ Date '7115 94) <br /> Additional Comments: �M _ <br /> Phase 11 Grout Inspection Pha a III Final Inspection <br /> Inspection By Date Inspection B byte / <br /> _ Fee Is Due: ❑ ANNUALLY hu ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar 11 July 1 &Received By July 31 <br /> $ REMIT <br /> BILLING REMITTANCE <br /> BASEEXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE .I <br /> LESS 1. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER II` <br /> - Iyli <br /> OTHER ilp <br /> r A <br /> hy <br /> Received by Dated' "Receipt No. ermit No. - Issuance Date -Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 a STOCKTON;CA 95201 <br />