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Applications Will Be Processed When Submitted-rp ..,:riPpieted. Be Sure To Sign The Application. <br /> FOR OFFICE USE: t APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL S <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 2-5_57q_ S� WATER QUALITY X30 —f 6 !' <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 San Joaquie Co my OOrrdina�]ce o. 1 2 a d the rules an4 regulations of the San Joaquin L Health District. <br /> Exact Site Address i H'��� 1 ,t�3r &4✓ A �'O?d City/Town �!�}��m <br /> Owner's Name D !� Phone <br /> Address 4*e- CiCity CS 64d 4iAnglov� <br /> Contractor's Name ' License# 19j" "711�Business Phone L <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ D? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ EC ONDITION El DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �{J i <br /> Sewage Disposal field Cesspool/Seepage Pit Other i�) <br /> Property Line Private Domestic Well Public Domestic Well <br /> P <br /> INTENDED USE TYPE OF WELL r� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ",1 <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Inst I <br /> PUMP INSTALLATION: Contractor CA <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done �• , <br /> PUMP REPAIR:-- ® State Work Done �c� �1 —___ Ile, t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <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 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 /> 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 /> Indill call for,/a Grout Inspection pr t�r tin a fl I inspection. <br /> Signed �r e: Date: 6 <br /> (Draw Plot PIVr on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date lG <br /> Additional Comments: <br /> Phase II Grout InspectionPhas IIJ.FJJinaI Inspection �y <br /> Inspection By Date Inspection By y Date J /Z <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE PATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> M <br /> Y _ 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 95201 <br />