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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ; <br /> FOR OFFICE USE: APPLICATION y <br /> (For Non-Transferable, Revocable,Suspendable) PIMP&WELL l/ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora.permitto construct and/or install the work.herein described.This application is <br /> made in compliance with San Joaquin County.Ordinanc No. 1862 and the rules and regulations of the San Joaquin ocal th District. <br /> Exact Site Address City/Town �Z •! �"--" <br /> Owner's Name <br /> KA" . Phone'. e, <br /> � _� <br /> Address City_[ <br /> Contractor's Name CS'7� yJ G� � License# ? 3 �Y�Business Phone <br /> Contractor's Address a 0 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With LH D? Yes X No 08 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ECONDITION❑ " DESTRUCTION❑ - .. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ -PUMP INSTALLATION ❑ PUMP REPAIRI t <br /> REPLACEMENT❑ 4 1 <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 Wel! <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATES ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 2 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Inst. ed By: <br /> PUMP INSTALLATION: Contractor <br /> Type'of Pump `Tsc H.P, �. <br /> PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: IN State Work Done n G <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure d <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. I <br /> Home owner or licensed agent's signature certifies the foliowin,g:•,'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." I <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 will call for a Grout Inspection pri 1 gra and a final-Inspection. Cf' <br /> Signed X CS-14 � itle: Date: <br /> (Draw Plot Ian on Reverse Side) <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � 0 Date <br /> -Application Accepted By <br />> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection I <br /> Ins ection <br /> Inspection By—nom - Date P B y - <br /> ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 FIF ❑ July 1 A Received By July 31 1 <br /> t REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE. EXPLANATION _ DATE DATE REMITTED AMOUNT <br /> FEE - <br /> LESS <br /> PRORATION - ,- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date - Receipt No. Permit No, - Is uance baie Mailed Delivere0 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />