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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) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work,.herein.described.This application is <br /> made in compliance with San Joaq 'n County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address 3 City/Town y 4(0 <br /> Owner's Name Or CL e 9k Got(`C_ t q_ Phone SO 5- ` F :5 scis 4 <br /> F <br /> Address s � " ' City '^ � od <br /> Contractor's Name _A1)llG_ License# ' Business Phone r' <br /> Contractor's Address ; Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No W <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO'd <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑. PUMP INSTALLATION ❑ PUMP REPAIR❑ V <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> CC Property Line Private Domestic Wel! Public Domestic Well ° <br /> INTENDEDQE TYPE OF WELL <br /> ❑ INDUSTRIAL'V& ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE.-.. ❑ DRILLED Dia. of Well Casing <br /> 11 DOMESTIC/PUBLIC w' ` 11 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ; ; ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION i-�" ❑ ROTARY Type of Grout <br /> °- <br /> ❑ DISPOSAL ❑ OTHER Other Information i <br /> I <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ( x <br /> PUMP INSTALLATION: [ Con'tr'actor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 'State Work Done I ! <br /> PUMP REPAIR, f ❑ State Work Done CA'1I <br /> DESTRUCTION OF WELL: ry Il�el1[5iamete�'" Ap roximate epth <br /> ;'Describe Material and Pr'cedure oIr <br /> I hereby certify that i have prepared @6096� ri8ation and,that the won will be one in accordance with San Joaquin CoJ'� <br /> ordinances, state laws, ar;d rules and regulations of the San Joaquin Local Health District n <br /> Home aw er or licensed a gent'signature certifies the following:"I certify that in the performance of the work for which this p <br /> is issued, snail not employ ar%y person.in such mannef; s to became subject to workman's compensation laws of Galifor <br /> Contrac is hiring or subcontracting signature certifies the following:"I certify that in the performance of the work forvr hic <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> II call for a Grout Inspection prior to grouting arl final inspection. <br /> Signed X •, tom] ,-4-44n& .. Title: _ Date: l <br /> I € (Draw Plot-Plan on Reverse Side <br /> FOR DEPARTMENT USE ONLY i r <br /> PHASE I <br /> Q no . <br /> Application Accepted By t Date <br /> Additional Comments: <br /> Phase II Grout InspectibnA Phase III F'nal Inspection <br /> Inspection By )r: i Date.' x InspeDate- 1 <br /> Fee IS Due: 11 ANNUALLY PER UNIT ❑'PER SITE ❑ EACH ❑ January 1 &Recei ed Ry January 31 ❑ July 1 &Received By July 31 <br /> 1 - BILLING REMITTANCE $ [ d REMIT <br /> BASE EXPLANATI011 7 AMOUNT DUE CHECKED <br /> t DATE @ DATE REMITTED AMOUNT <br /> FEE t. <br /> LESS, <br /> PROATION <br /> PLUS€ <br /> PENALTY <br /> _ f <br /> OTHER <br /> OTHER <br /> 3L LL2 <br /> It <br /> 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 />