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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F FICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> s ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is d <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. " <br /> Exact Site Address 01 e City/Town /'��sC4 cwAv_• + <br /> Owner's Name eN Phone?IrZ — S'� G'7 _40 <br /> Address 7/f City <br /> S Contractor's Name License# � Business PhoneG_ �� <br /> -Contractor's Address Emergency Phone 16 <br /> Is Certificate of Workman's Compensation Insuran a r) He With SJLHD? Yes jr No <br /> { <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRCd� <br /> REPLACEMENT❑ <br /> r 1 <br /> DISTANCE TO NEAREST: Septic Tank 7 Sewer Lines Pit Privy <br /> 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information f <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t/ �j <br /> Type of Pump S`d� H.P.—_7/ d <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: RkState Work Done <7A40!r, ArD`o/Lr <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. O <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 /> I 11 call for a Grout Inspe prior to grouting and a final inspec' n. <br /> Signed X Title: Date: <br /> Draw Plot Plan on Reverse Side) <br /> FOR DEPAR MENT USE ONLY <br /> PHASE I C� <br /> Application Accepted By 44_, <br /> Date <br /> Additional Comments: <br /> I Phase 11 Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El 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 t <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS O r <br /> PENALTY <br /> OTHER i <br /> i <br /> OTHER I <br /> i <br /> i Received by Date Receipt No. .,,..; Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZ£LTON AVE.,P.O.Box 2009 STOCKTON,CA 952ca; <br /> L' - - - f <br />