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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 PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made toth.��jjSanrJ a n ocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San JXSca iln 4AJ Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Towni'9.�/�i%y1S <br /> Owner's Name Phone <br /> Address _ City <br /> Contractor's Name e0 S.C4 icense#-7 & OJS / Business Phone <br /> k Contractor's Address aS /ZPt Aedr;I17 Emergency Phone g 47-- 12'_2 G,[ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLJM DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank S7 f Sewer Lines Pit Privy A-1 Q !! 1 <br /> Sewage'Disposal Field 417 /. Cesspool/Seepage Pit /(_1 6/0 : Other Vt <br /> Property Line Private Domestic Well X�— Public Domestic Well 1 <br /> INTENDED USE TYPE OF WELL I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing SY IV <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �^^ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal a <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information <br /> r <br /> f ❑ GEOPHYSICAL _ Surface Seal Installed By: <br /> d � 6 <br /> PUMP INSTALLATION: Contractor S_� <br /> - Type of Pump H P Ser <br /> PUMP REPLACEMENT: '❑ State Work Done <br /> PUMP REPAIR: i:El State Work Done )t <br /> DESTRUCTION OF WELL: Well Diameter _ - <br /> - _ � .Approximate Depth:--- <br /> Describe Material and Procedure <br /> 1 <br /> I <br /> x 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 /> l Home owner or licensed agent's signature certifies the following:A certify that in the performance of thework forwhich this permit <br /> t 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 p ersons subject to workman's compensation laws of California." <br /> will call for a G out ec on p for o grouting and a final inspection. <br /> — <br /> Signed Title: '�' Date: U <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By�+ DateIt1J11-2� <br /> Additional-CWfnmen <br /> f Phase II rout Inspection Phase III Final Inspection <br /> <1s <br /> :E1 <br /> By Date Inspection By 4 A v 1, a DI <br /> ANNUALLY ❑ PER UNIT ❑ PER SIT EACH ❑ January 1 &ReceivedBy.January 31 ❑ July 1 &Received By July 31 <br /> —17 BILLING REMITTANCE $ REMIT <br /> ANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE / ` l �_��• <br /> LESS Blry Sri UdGJIi� <br /> I PRORATION f ? <br /> PLUS }. J IE a auJti . <br /> L PENALTY (,�Ci y <br /> € ro-v •I- d(� Po ee v <br /> OTHER pg / I.s <br /> r <br /> 'OTHER <br /> J. <br /> Rec wed qy Dae t Receipt No. Permit No. v Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: r ENVIRONMENTAL HEALTH PERMIT/SERVICES - -1601 E.HAZELTON AVE.,P.O.Box 2000 STOCKTON,CA 95201 <br />