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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) PUMP&WELL <br /> " ENVIRONMENTAL'HEALTH PERMIT <br /> t <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY •�$ft i r.w�. <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permit to construct and/or install thework.herein described.This application is + <br /> r made incompliance with San oaquin Coety Ordi pante No.,1 62 and the rules and regulations of the San oa uin Local Health Diptrict. <br /> Exact Site Address City/Town / Al <br /> Owner's Name :!/R A_'- Phone_.We 115_ S <br /> Address 5`y ' 1 <br /> cj' - : City ' ri }.t A: &J y� <br /> Contractor's Name ' License#322SS Business Phone "` �' / I <br /> Contractor's Address _G' �oX/�ff GUct7C��i2%�GC Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes *rte No <br /> TYPE OF WORK (CHECK): NEW WELL®—_DEEPEN ❑ RECONDITION❑ ' DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ _ Q <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /`c?J Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other IJ <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation f <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /2 <br /> -9 IRRIGATION ,.fie'GRAVEL PACK Depth of Grout Seal <br /> 1:1A <br /> CATHODIC PROTECTION ROTARY Type of Grout T T <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL -- - - m Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 k <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 will call fora rout Inspection prior to grouting and a final inspection. <br /> Signed X S Title: __ _ Date: -- Z <br /> " (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted = Date <br /> Additional Comments: <br /> Ohase If Grout Inspection Pha_sJ� I Final Inspection <br /> Inspection By ' 1 Z Date Inspection By e Date f <br /> Fee Is Due: ❑ ANNUALLY ' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By'January 31 ❑ July 1'&ReceiVed By July 31 <br /> BILLING REMITTANCE. REMIT <br /> EASE- ' EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �w. y Q 00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER y <br /> OTHER r -i ♦ i r' �- _ . -. <br /> i <br /> ri <br /> Received by Date - Receipt No. PiirmiT No, Iss ante D to Mailed -Deliverea <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />