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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application – s <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WE.L <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install thework.herein described.This application is <br /> made in compliance w� an Jo in County Or nce N . 18 an a rules and regulations of the 5 in Local Health District, <br /> Exact Site Address D F City/Town //1l`*�'G�d –N– �lJ. <br /> Owner's Name �7� e - Phone ^^ d <br /> Address �- City C <br /> Contractor's N A (cense (oe'�s� Business Phone –� <br /> Contractor's Address <br /> Is Certificate of Workman's Compensation Insurance on Fife With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLZ�-_ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ C9 <br /> REPLACEMENT❑ )' 1. <br /> DISTANCE TO NEAREST: Septic Tank Sower LinesPit Privy <br /> Sewage Disposal FieldrJ`� Cesspool/Seepage Pit ,���-. Other <br /> Property Liner– y Private Domestic Well "-^ Public Domestic Well <br /> INTENDED USE TYPE OF WELL f <br /> ❑ IND +RIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 9`DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ! 57s" <br /> !� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal R , <br /> ❑ CATHODIC PROTECTION 'F�TARY Type of Grout .V dey cT' <br /> ❑ DISPOSAL ❑'OTHER Other Information . 1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �hLa�i <br /> PUMP INSTALLATION: Contractor N <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 /> 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall emplo ns subject to workman's compensation laws of California," <br /> Ill call for a Gro t In to In rior t grouting and a final inspection. <br /> Si t Title: 4'1 a. Date: <br /> Draw Plot Plan on Reverse Side) <br /> g FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> �kte,voty'rokms Phase II Grout Inspection Phase III Final Inspection <br /> /4lk'-C Inspection B� 7/",F/ c� Date Inspection By g Date <br /> o 4zr yr o v <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE- ❑ EACH ❑ January 1 &Received By January?31 ❑ July 1 &Received By July 31 'yy <br /> eo - REMIT f <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED . AMOUNT DUE CHECKED <br /> 1 AMOUNT ' <br /> FEE <br /> LESS <br /> PRORATION <br /> PENALTYPLUS <br /> OTHER 1'L'i2�D 6 iL^t fPua" 0( ti✓� <br /> OTHER t <br /> lam- I` `� <br /> Received by Date FrelcWt No. Permit No. ssuance Date Mailed red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' -„� 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201 <br />