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. <br /> Applicatlons 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 y, <br /> Application is hereby made to the Sari 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. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address c <br /> Owner's Name - Phone <br /> .„�T City <br /> Address <br /> Contractor's Name r License#Iir,!7�,n_G_ Business Phone, ,931-3210,: . l <br /> Contractor's Address —2-1_t'0Wilclew—Rd. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW-WELL❑ DEEPEN ❑ RECONDITION-11 --DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONZ 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 /> a <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED 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 Surface Seal installed By:. <br /> PUMP INSTALLATION: Contractor Moorman s Waf-er Sy <br /> 1 Type of Pump gi . E? <br /> b— -?rslb-1H.P. .r <br /> PUMP REPLACEMENT: }I State Work Done ' <br /> PUMP REPAIR: } ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth #� <br /> I Describe Material and Procedure + i <br /> I <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.. j ) <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 snail 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 /> 1 will call for Grout Inspection-prior to grouting and a final Inspection. <br /> Signed X Title: Date: i <br /> (Draw Plot Plan on Reverse Side) t <br /> I <br /> FOR DEPARTMENT USE ONLY I E <br /> PHASE 1 1 1 �� 0 <br /> # � .' WLS -� t Date <br /> Application Accepted By j <br /> Additional Comments: t <br /> Phase III Final Inspection <br /> }Phase II Grout Inspection � <br /> I Inspection By Date Inspection By Date <br /> F f <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 /> .ter <br /> FEE <br /> i LESS- _ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER D <br /> Received by Date Receipt No. Permit No.- I uance to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />