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'_Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR,OFFIC�E 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 madeto the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin Cou Ordinance 62 and the rules and regulations of the San o quin Local Health District. <br /> :-Exact Site Address Q6403 �8_Z City/Town Z5 0410 A17 <br /> i <br /> Owner's Name �f],!� <br /> ,6 JV z X-x 1? Phone <br /> Address .4)7, City �Crl-� O� <br /> { Contractor's Name License#%,2790/d Business Phone f!UA. U <br /> Contractor's Address c�_c9C7.a Yd qJ/U % Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes IWA No <br /> TYPE OF WORK (CHECK): NEW WELL C] DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _Pit Privy <br /> ~ Sewage Disposal Field Cesspool/Seepage Pit Other <br /> t Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> E ❑ 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 /> L ❑ DISPOSAL ❑ OTHER Other Information 4 <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 0 <br /> r Type of Pump H.P. L <br /> 4 PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done C <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth s <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 /> e' ordinances, state laws, and rules and regulations of the San Joaquin 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 /> a is issued, I shall 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 /> I will qafl for a Grout Inspection_prior to grouting and a final inspect' <br /> Signed X - Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEFARTMEV USE ONLY <br /> G PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> h Phase II Grout Inspection P se I Final h�pection <br /> Inspection By Date Inspection B�/°� ate <br /> Fee Is Due: ❑ ANNUALLY ❑ pER UNI!; ;_; PER SITE ❑ EACH t❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE E F?LANATIQN{ t' ZILLINGf ,Q REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE REMITTED AMOUNT <br /> ,FEE <br /> R LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Yrs fjn�/ 79 'SCA--S. -7n-�-1p�75 <br /> Received by - Date Receipt No. Permit No. Issuance Date - Mailed Delivered <br /> ` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 O1 <br />