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r f Applications Will Be Processed When Submitted-Properly Completed. Be Sure To Sign The Application. <br /> OR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <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 with n Joaqui County dinance No. 1862 and the rules and regulations of the San Joa in Local Health District. <br /> Exact Site Address d 4RA r6sr City/Town <br /> [ Owner's Name + - Phone GZ'510.3 <br /> Address IR1 CAA �n City a <br /> Contractor's Name L�.t E tf 0 /1,1 License#]L GO-3 Business Phone Tl(O Z� r <br /> h Contractor's Address Z+ % G Emergency Phone <br /> (a X_ es Z� <br /> Is Certificate of Workman's Compensation Insur on Fil With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f ( <br /> too b C <br /> DISTANCE TO NEAREST: Septic Tank o Sewer tines 1 o o Pit Privy <br /> r- <br /> Sewage Disposal Field Cesspooi/Seepage Pit Other <br /> Property Line d r Private Domestic Well rPublic Domestic Well r� <br /> INTENDED USE TYPE Of-WELL <br /> a ❑��I .RIM4Lr_:...,�,.._.�,:.._.r..,�..,�,�K;-..�w=..�❑�CY�B�E-TbOL...:.�::.: ' .Dia.-ot=5Ne11�Excavaiion. - - - -. <br /> 1 DL'S OMESTIC/PRIVATE ❑ DRILLED ._ _,1,qia. of-WOl Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �Z ! <br /> t ❑ IRRIGATION ❑ GCPACK Depth of Grout Seal " <br /> 11 CATHODIC PROTECTION ROTARY Type of Grout 1 <br /> rE <br /> ❑ DISPOSAL ❑ OTHER Other"Information,-. w <br /> ❑ GEOPHYSICAL_ Surface Seal Installedy, �- <br /> PUMP INSTALLATION- Contractor <br /> Type of Pump H.P. <br /> r PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State-Work Done x <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> j Describe Material and Procedure n <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 /> Htime owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit- <br /> is Isued,l-shall.pot 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 /> 1 will call for a Gi•out Inspeciio prior to grouting and a final ins ction. € <br /> /9 <br /> Signed X d Title: Date <br /> a (Draw Plot Plan on Reverse Side) t <br /> t FOR EPARTM T USE ONLY <br /> PHASE I I/ ' <br /> k Application Accepted'By cJ Date <br /> Additional Comments: <br /> 'Ph as 11 Grout Inspection Phase III Final Inspection <br /> Inspection By—'. Date /0' r 99 - Inspection By_42 ., Date <br /> k <br /> Fee Is Due: EJ ANNUALLY El PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ 1 REMIT <br /> .BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> .AMOUNT <br /> r FEE X!Y2 Se <br /> L� <br /> LESS - <br /> PRORATION i } <br /> PLUS i <br /> PENALTY r .� <br /> OTHER <br /> OTHER <br /> 779—1Q—Iri <br /> Received by Date Receipt No. Permit No. Issuance Dae Mailed befiverea <br /> APPOCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />