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aApplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR- OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable;Sus futile) PUMP&WELL <br /> V �4ENVIRONMENTAL-HEALTH�PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY_ <br /> : i.C3 1C) Of 19ft' y <br /> Application is hereby madeto the San Joaquin Local Health District for a permitto construct and/or install the work,herein described.This application is <br /> made incompliance with.San Joaquin County Ordinance-Vol 186 and the. rules and regulations-of.the.San.J quin oral Health District. j <br /> Exact'Site Address Sa C�V-2- City/Town <br /> Phone <br /> Owner's Name "t' <br /> Address TI/ Gtr. City <br /> ,� ,t - Business Phone 3 <br /> Contractor's Name License#f � T <br /> ...•.., :- ,.- - .�.;- .. � '•'Emergency Phone _ ' �Ca�^c�� <br /> Contractor's Address d t I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? _ Yes v No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11 RECONDITION❑ DESTRUCTION I] <br /> i TION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR _A <br /> WELL CHLORINATION t�Y <br /> REPLACEMENT❑ ? <br /> DISTANCE TO NEAREST: Septic Tank,_ Sewer LinesPit Privy <br /> ",-Cesspool/Seepage Other <br /> ool/See a e Pit er 1 <br /> Sewage Disposal Field P P 9 , <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE <br /> TYPE OF WELL } = p <br /> I- x - i <br /> ❑ INDUSTRIAL ❑ CABLE,TOOL Dia- of Well Excavation <br />{ ❑,DRILLED Dia. of Well Casing �. I <br /> ❑ DOMESTIC/PRIVATE ` <br /> - 1 DbMESTIC%PU8LlC._� r _ -❑ DR111EN �_ : , Gauge of Casing 1 <br /> ❑ IRRIGATION ' ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER 4� Other Information <br /> ❑ GEOPHYSICAL s Surface Seal Installed By: <br /> PUMP INSTALLATION:; Contractor <br /> Type of Pump H.P. Q <br /> PUMP REPLACEMENT: ❑ State Work Done1. <br /> PUMP:REPAIR: C State Work Done w �' <br /> r " .-�! r Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter N <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 Sant. <br /> Local Health District <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 shall not employ any person in such manner as to become subject-to'workman's compensation laws of California." C <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this C� <br /> permit is issued, I shall employ persons subject to workman compensation laws of California."-. yt <br /> I will c Ill a Grout I ection prior to outing and a final inspection. <br /> r �s+ itl'e: Date: <br /> Signed X —_� 1 <br /> (Draw PIotPlan on Revers Side) <br /> ^ � -4 FOR DEPARTMENT USE ONLY <br /> PHASE I Date o 1 <br /> Application Accepted <br /> Additional Comment_ <br /> F Phase-II Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By - Date } <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 /> FEE S c m } <br /> PRORATION e <br /> PLUS i <br /> ` PENALTY - - <br /> OTHER <br /> I <br /> OTHER <br /> issuance Date Mailed Delivered <br /> Received by <br /> Date Receipt No. Permit No. _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />