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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> '— (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Healt District for apermi construct and/or install the work herein described.This application is <br /> made in compliance wijj San Joaquin County Ord in cee , X6;55d4Zthe rule and regulations of the San Joaquin Local Health District. <br /> r Exact Site Address f ;f 4 rrM ii a t + Ja City/Town 5 <br /> Owner's Name/�t �� ��?� t t Phone <br /> Address - � Q,IS���U City <br /> Contractor's Nam_,e it � 1-oSF � ���`�� License# �Business Phone <br /> Contractor's Add"Agkiy - � �t-Sre- -- � Emergency Phone <br /> ' Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No <br /> TYPE OF WORK (CHECK): NEW WELL��DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ �{� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ - OTHER(,.❑ PUMP INSTALLATION 8-' PUMP REPAIR❑ V <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /6 C� Sewer Lines l :i Co Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property LinePrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> -CrOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal d <br /> ❑ CATHODIC PROTECTION —MTARY Type of Grout 5 CC <br /> ❑ DISPOSAL ❑ OTHER Other Information O <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. L <br /> r , ,UMP REPLACEMENT: ❑ State Work Done <br /> P _P REPAIR: © State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> F. <br /> I Describe Material and Procedure <br /> t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> F ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. " <br /> r <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 /> i 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 /> II7wiilll ccall for a Grout Inspection prior to grouting and a final inspection. 4 A <br /> Signed .`t �+ Title: (;; - Date. <br /> i (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: -dee ' "� �. <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date _ Inspection By Date <br /> € Fee Is Due: ❑ ANNUALLY Cl PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> r yI REMIT <br /> BASE EXPLANA710TI BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> }DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS e 1 <br /> PENALTY f} <br /> I OTHER -p v <br /> OTHER <br /> [ Rec ived by Date Receipt No Permit No, Issuance Date Mailed Delivered <br /> APPLICANT:;RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />