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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: APPLICATION 9 <br /> (For Non-Transferable, Revocable,Suspendable) <br /> = PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San�.J�o,ya_q_uin cyallHHe� District. <br /> Exact Site Address rI L� 4 City/Town s f e f <br /> Owner's Name ' '4'1 ' P Phone ^ <br /> Address r +. r r City re k ,•� <br /> Contractor's Name � 7 c o, License# ✓ Business Phone s <br /> rr <br /> Contractor's Address `.s'j 21 9 y <br /> v Emerenc Phone ' r <br /> Is Certificate of Workman's Compensation Insurance on File With SJ LH D? Yes_ fir"' No j <br /> TYPE OF WORK (CHECK): NEW WELL 13DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ IF <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ 6 <br /> REPLACEMENT❑ ) <br /> DISTANCE TO NEAREST: Septic Tank f Sewer Lines Pit Privy <br /> Sewage Disposal Field s F Cesspool/Seepage Pit Other <br /> Property Line ar`,*' 4 Private Domestic Well f� Public Domestic Well. ^ '° Jr <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE © DRILLED Dia. of Well Casing <br /> ❑ UQMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 42 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout s <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor '. <br /> Type of Pump • t, 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 Prbcedure <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 bf 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 Groins ection prior to grouting and a final inspe n. •�' ,l }� <br /> Signed X f'•,le _ , - i!" Date,///5/ <br /> Title•.. <br /> S (Draw Plot Plan on everse Side) <br /> F07 DEPARTMENT USE ONLY- 4 <br /> PHASE ! .� � r`� <br /> �z <br /> Application Accepted By <br /> "'` "`�" "� Date / <br /> r <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase 111 Final.inspection, <br /> Inspection By Date Inspection By Date <br /> Fee Is flue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE t-' ° <br /> T; <br /> LESS <br /> PHORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601.E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />