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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ` FOR OFFICE_ USE: APPLICATION <br /> .� (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 County Ordinances No. 1862 an the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address N d�=-�� o d I 't J� City/Town <br /> Owner's Name A~ � �" I Phone 33 <br /> Address . <br /> " City <br /> Contractor's Name �,e-vLa�. License#/k 1 32-3 Business Phone <br /> Contractor's Address C9 Emergency Phone `"F f- -1 Sr <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No 6` <br /> TYPE OF WORK (CHECK): NEW WELL❑ 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 /> t Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal C <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout .+C <br /> ❑ DISPOSAL ❑ OTHER Other Information o(1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: dQ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump s H.P. t <br /> PUMP REPLACEMENT: ❑ State Work Done . <br /> PUMP REPAIR: State Work Done 4- K — <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth a <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I cap for a Grout pection prior to ting and a final inspection. <br /> Signed Xtle: 7 4, Date: <br /> (Draw Plot Plan on Reverse S' e) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase It Grout Inspection h e i Final I pectio <br /> Inspection By Date n Inspection By Date % ��'s�"(50 <br /> Fee Is Due: 11 ANNUALLY El PER UNIT ❑.PER SITE ❑ EACH El January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT ` '� <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. <br /> Su <br /> Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 HA2 AY P.O.Bax 2009 STOCKTON,CA 95201 <br /> -_- _ �� / / <br />