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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. (GI <br /> FOR OFFICE USE: APPLICATION 1 <br /> (For Non-Transferable , Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE , <br /> ( ) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District for permitto construct and/or install thework herein described.This application is <br /> made in.compliance with Sw Joaquin Cgunty Or "nance No 1862 "d t e rules a d regulations of the San"uin.Local Health District. <br /> Exact Site Address Gk/ City/Town - <br /> p. � <br /> Owner's Name I.b1h p� t f Phone + �2?�~ <br /> Address //�� ��;-..�ttC•.: 'i`f�t O'[ Ff/ *z. .� :_ -City' <br /> Contractor's Name Cst..[[.tA&_ �ii- (I rlu "License# 3�. 5~ Business Phone. <br /> Contractor's Address 3v d, Emergency <br /> hone <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELIL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ w ' <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank of � Sewer Lines �d a]� Pit Privy <br /> Sewage Disposal Field fUOr – Cesspool/seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic,Well <br /> INTENDED USE TYPE OF WELL {� <br /> ❑ INDUSTRIAL E] CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE !11DRILLED Dia. of Well Casing ; <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION X�GRAVEL PACK- Depth of Grout Seal — <br /> ❑ CATHODIC PROTECTION X ROTARY Type of Grout <br /> ❑ DISPOSAL R ❑ OTHER y Other Information 4 ow4�� <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 WELL: Well Diameter 5 *Approximate Depth <br /> Describe Material and Procedure <br /> 1 <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 /> Home owneror licensed agent's signature certifies the following:"I certify that in the performance of the work for whichthis 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 /> Conlractor's hiring or sub-contracting signature certifies the fallowing:"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 /> I - <br /> I will call for a Grout Insp tion prior to grouting and a final inspection. <br /> Signed X'_ Title: GGdVwL Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> Application Accepted By - i - = Date ` ! <br /> Additional Comments: x' _ <br /> Ph9se 11_A rout Inspection`' q ,t Phase III final Inspection " <br /> Inspection By 11M.14111 Date/ ` - Inspection By - $ _- Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE y- ❑ 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 i DATE REMITTED AMOUNT <br /> FEE r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY t t' <br /> OTHER ` <br /> OTHER <br /> LD <br /> Received by - F Date - Receipt No. s Permit No: - Mss nce Dat -Mailed, Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bok 2009 STOCKTON,CA 95201 <br /> 4 .c <br />