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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 /> ENVIRONMENTAL HEALTH PERMITPUMP&WELL <br /> . 4 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the 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 Joaquin Co4nty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health Distric <br /> Exact Site Address / m*//*t ic ok AIL-_,0 City/Town — <br /> Owner's Name Phone <br /> Address �G 7Y City 3 <br /> ' <br /> Contractor's Name License# 73-�(_ �6 y -7t 7-Business Phone �i <br /> Contractor's Address D Emergency Phone <br /> • <br /> Is Certificate of Workman's ompensation Ins ran eon 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 /> 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 /> ❑ 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 ❑IOTHER Other Information f <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ."7kM1 <br /> T i/ ♦b -H.P. -7,X — t <br /> Type of Pump _ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: JS State Work Dane4g 4k• ��asF ''� <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. <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 /> x <br /> Contractor's hiring or sub-contracting signature certifies the following:1 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 /> CCI will <br /> --call for a Grout Inspection 1 gr utin and a I al inspection. <br /> Signed xs �"' c9<•, itle: �Flrat _ _. Date: V <br /> U- (Draw Plot Pan o.�,Reverse Side) <br /> FO EPARTM NT USE ONLY <br /> PHASEI <br /> Application Accepted By Dat <br /> Additional Comments: <br /> Phase II Grout Inspection a III Fi Inspection <br /> Inspection By Date Inspection Date z, 9 _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REWT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION` AMOUNT DUE CHECKED <br /> --m --- DATE DATE. REMITTED AMOUNT <br /> FEE <br /> LESS pgo <br /> PRORATION <br /> PLUS <br /> PENALTY _ T <br /> t <br /> OTHER <br /> - OTHER <br /> y , <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Deiivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,CA 95201 ' <br />