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Applications Will Be Processed When Submitted ProperlyCompleted. taesure io sign I"%: <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable, Suspendable) PUMP&WELL � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and relations of the San Joaquin Local Health District. <br /> Q U/ L m Q City/Town <br /> Exact Site Address-7- j <br /> Owner's Name <br /> JNr/1 � 11p Phone ''- �-Z� Z• <br /> City <br /> Address Q �aCy / --- <br /> o License# 321 &l-= Business Phone -Z 9` <br /> Contractor's Name Z oz� <br /> Contractor's Address ;j�0 �.`i I-�`i �c�-f � Emergency Phone <br /> Is Certificate of Workman's Compensation Insura ecn on File With SJLHD? Yes ✓ No — <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ 'RECONDITION[] DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> ••-- BI-ST-ANGE TO NEAREST: Septic Tank _ /Od Sewer Lines Pit Privy y <br /> Cess pool/Seepage Pit �'� Other <br /> Sewage Disposal Field 1 o <br /> Property Line_1(� Private Domestic Well Public Domestic Weil �— <br /> INTENDED USE TYPE OF WELL <br /> ❑_, I>DUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> L- DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing tQ <br /> 11DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing <br /> ❑ IRRIGATIONGRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> OTHER <br /> Other information <br /> 12 GEOPHYSICAL Surface Seal Instilled By: `� <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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"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 forwhich this <br /> permit is issued; I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call for a Grout Ins p ction prior to grouting and a final inspection. <br /> - e .. ' <br /> i RJr� � Q r Title:- Dale: _ <br /> Signed X �.F�,c-�'.. , <br /> Dr w'Plot Plan on Reverse Side) <br /> FOR <br /> ✓ DEP RTMENT>L E ONLY:.—,. <br /> PHASE I r f . . _ Date �'r �'r <br /> } Application Accepted By. <br /> a Additional Comments: <br /> -�— Phase III Final Inspection <br /> t Phase 11 Grout inspection <br /> Inspection By <br /> Date Inspection By Date <br /> *f <br /> Fee IS Due: ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT my 31 <br /> BASE `� ExPLANATION -BILLING- REMITTANCE - $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> • FEE �� - �. - - �•- .. - .. ���' L/� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> �7 c! <br /> r y [� <br /> o { P 3 'Z C ?d <br /> Received by <br /> Dat Receipt o. Permit No. Issuance Delivered <br /> ate Mailed _- � <br /> /SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 209,.. STOCKTON, 95201 <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMIT <br />