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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: q !! APPMATON' <br /> (aYkFG/b (For Non-Transferable, Revocable,Suspendable) PUMP&WELLS <br /> ENVIRONMENTAL HEALTH PERMIT P T� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY .�,.4 s <br /> F y,..,,,. . , <br /> Appl ication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This appI ication is <br /> made in compliance with San Joaquin County Ordinance No.1862 an es and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ; � x�G i City/Towni <br /> Owner's Name ir ra e Gds y" Phone`. " <br /> .rtr .t i '1`3 f <br /> Address �: �Y City <br /> Contractor's Name 1' y License#/^r? !7A-e Business Phone <br /> Contractor's Address ?Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL' ❑� DEEPEN ❑ RECONDITION DESTRUCTION❑"�`� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0-1 OTHER ❑ PUMP INSTALLATION PUMP-REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy , <br /> v. Sewage Disposal Field _.--'3-CesspooVSeepage PitOther �fJ <br /> Property Line - Private Domestic Well Public Domestic Well ` <br /> INTENDED USE TYPE OF WELL . <br /> ❑ INDUSTRIAL i`❑ CABLE TOOL Dia. of Well Excavation <br /> DOM STIC/PRIVATE II❑ DRILLED Dia. of Well Casing <br /> OMESTIC/PUBL ';❑ DRIVEN Gauge of Casing I <br /> ❑ IRRIGATION ��❑ GRAVEL PACK. Depth of Grout Seal k <br /> ❑ CATHODIC PROTECTION Al ROTARY Type of Grout <br /> ❑ DISPOSAL f❑ OTHER Other Information <br /> ❑ GEOPHYSICAL T Surface Seal installed By:' <br /> PUMP INSTALLATION: IEE Contractor - � <br /> E.. nTYPe of Pump H.P. �. <br /> PUMP REPLACEMENT: i❑ State Work Done (a <br /> PUMP REPAIR: !'❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> -i 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 /> yr . <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 workrnan's.compensatioli laws of Galitornia."-., <br /> v Contractors 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 will call for a Grout Inspection pr ou fng a a finali ection. - <br /> Signed /I� e. tate: <br /> (Draw Plot Plan on verse Side) <br /> FOR DEPARTMENT USE-ONLY <br /> PHASE I -y � i'A <br /> Application Accepted-Sy Date`r' l-- A <br /> Additional Comments: 1 <br /> Phase 11 Grout Inspection � hasE*II I Inspectio <br /> Inspection By_ xDate In ,By at - <br /> � w <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> i PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I OTHER <br /> L <br /> - - - - <br /> Received by DateI-- + -� Receipt No. - - Permit No. --. suan 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 /> I <br />