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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 /> COMPLETE IN TRIPLICATE WATER QUALITY a ,. ,r , f,- <br /> Application is hereby madeto the San Joaquin Local Wealth District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqui ounty Ordinance o.1862 and the rules and regulations of the San Joaquin Locai Health District. <br /> Exact Site Address �� 2G,>� x City/Town 46 <br /> Owner's Name :_ ++V° F �• Phone <br /> Address ' � t f t r- CityG133 <br /> Contractor's Name . �. '�• c- �� ­:License 62- 10 Business Phone' <br /> fContractor's Address ' 4Jii f -` " Emergency Phone <br /> Yes �h No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? <br /> TYPE OF WORK (CWECK): NEW WELL❑ DEEPEN ❑ ' RECONDITIOND, DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑• OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank -Sewer Lines Pit Privy <br /> Sewage Disposal Field' '' r t= Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ` <br /> ®' DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ,. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge-lot Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> C3CATHODIC PROTECTION ❑ ROTARY # Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal.installed By: <br /> PUMP INSTALLATION:. Contractor <br /> Type of Pump . -.ems H.P. <br /> PUMP REPLACEMENT: ® State Work Done srtiv>i IS 6. 41, <br /> PUMP REPAIR: Cl State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth --(� <br /> Describe Material and Procedure ) ! <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County. <br /> F 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 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." .� { <br /> I wtl cal for a Grou ns ectio prior to grouting and a final inspects n. /� �/ <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY l <br /> PRASE I Date <br /> Application Accepted By `^"'� - <br /> Additional Comments( <br /> Phase II Grout Inspection xPhase Final Inspection <br /> Inspection By Date J Inspection Date <br /> Fee Is Due:-❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE ' - EXPLANATION JBILLING REMITTANCE.. $ - - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4s <br /> r LESS <br /> PRORATION <br /> PLUS <br /> F PENALTY <br /> OTHER <br /> OTHER <br /> ov <br /> Received.by t Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETUR14'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SEfiVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />