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..� �. , <br /> Applications Will Be Processed:Wren Submitted Properly Completed. Be Sure To Sign The Application. <br /> ]_ <br /> r= " APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT I <br /> rr IC^: <br /> (COMPLETE IN TRIPLICATE AU!—"ii IM WATER QUALITY,., . .„ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is I <br /> made in compliance wittl San/Joaquin Cc ty Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address! `/� .3 e - City/Town <br /> Owner's Name t Phon\wAj 7_10e <br /> one,1 � Y <br /> Address `t? pity" <br /> Contractor's Name License# L� Bus eas Phone 7 <br /> Contractor'sAddress '1 r. Emergency P�h�o/n <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes /1 No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑' DESTRUCTION❑ <br /> WELL CHLORINATION Cl WELL ABANDONMENT ❑ - -OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 " <br /> REPLACEMENTS i <br /> DISTANCE TO NEAREST! Septic Tank 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 /> IV DOMESTIC/PRIVATE , ❑ DRILLED " Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN € Gauge of Casing <br /> ❑ IRRIGATIONS, ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY ! Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL i 1 Surface Seal Installed By: <br /> s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done .'^ —!—"y� �- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> Describe Material and Procedure r <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with$an Joaquin County <br /> ordinances, state laws, and rules and regulations of the Sari Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:'ji 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 certity that in the performance of the work for which this <br /> j permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t <br /> l w9rhall for a Grou pecti prior to grouting and a final inspec ' - , <br /> Signed X L Title: I Date: r �� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> <•—�-�_,--�'"�— <br /> Application Accepted y• <br /> Additional Comme_.n _ <br /> Phase 11 Grout Inspection —Phase_r III Final Inspection <br /> Inspection By Date Inspection By,-Z' <br /> y •C Date S ? <br /> 'f +� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> cOTHER <br /> S9 71KF <br /> Received byDate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Dox 2009 STOCKTON,CA 95201 _a <br />