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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) <br /> PUMP&WELL <br /> y-- ENVIRONMENTAL HEALTHIPERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY. <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with S n JoZ/19 7aquin Colty Ordin nce No. 2 and t e rule d regulations of the San Joaquin Local Health District. <br /> Exact Site Address / City/Town <br /> Owner's Name _ 1�� fC `" � ��11��1 Phone <br /> Address ;%� �City <br /> Contractor's Name '06 I nse#GZ1���`�` Business Phone <br /> Contractor's Address Zmergency Phone <br /> 1 Is Certificate of Workman's Compensation Insu nce on File With SJLHD? Yes �� No <br /> TYPE OF WORK (CHECK): NEW WELL m�DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ,� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _/Z5�CJ eA— Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit 2-77 Other <br /> Property Ling_21�Private Domestic WeIIL +Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INPUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation fllt�dC�` 1 M <br /> ReDOMESTIC/PRIVATE rL�RILLED Dia- of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /'2- <br /> IRRIGATION <br /> Z <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _ t- <br /> ❑ CATHODIC PROTECTION NOTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> t ❑ GEOPHYSICAL Surfpce Seal In al ed By: <br /> PUMP INSTALLATION: Contractor S <br /> Type of Pump H.P- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> F <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 /> t' ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <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 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 /> I w' 11 f a G ns ion prior to grouting and a final inspection. <br /> Signed X e: AY Date: r e <br /> ( (Draw Plot Plan on Reverse Side <br /> - -r <br /> s FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted ByX\1 ­_ I QDate <br /> I Additional Comments:' <br /> E Phase 11 Grout Inspection PlAs Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT . ❑ PER SITE- ❑ EACH ❑ January 1 &R(,,,./dEy January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE Ilk CHECKED AMOUNT <br /> f p i O <br /> FEE <br /> LESS s <br /> k PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 4 <br /> '07313 x-3140 <br /> Received by Date Receipt No. Permit Na- Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMITISERVICES - 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />