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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 /> I ENVIRONMENTAL HEALTH PERMIT r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 9862 d the rules and regulations ofthe Sanj�aquin Local Health District. <br /> Exact Site Address City/Town ![ <br /> /^ / <br /> Owner's Name bN /Y "' Phone 3 <br /> Address 7 '7 17 eY, City <br /> Contractor's Name Ali je b #,�K?lly "Business one jg�L/�- <br /> Contractor's Address Emeegency Phone <br /> .Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _. _ No <br /> TYPE OF WORK (CHECK): NEW WELL- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ I I <br /> DISTANCE TO NEAREST: Septic Tank 0 Sewer Lines 52;! ± Pit Privy <br /> Sewage Disposal Fipld Z f Cesspool/Seepage Pit Other <br /> Property Lineo/O�. Private Domestic Well��Ili4- Domestic Well <br /> INTENDED USE TYPE OF WELL n <br /> ❑ INDUSTRIALCABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> PtlRRIGATION r• ❑ GRAVEL PACK Depth of Grout Seal " <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: /fQZA�� <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 <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 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 fallowing:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons ct to workman's compensation laws of California." <br /> I II for a Grou I specii prior outing and a Fina! inspection. <br /> Signed X Title: ►ti! Date: <br /> 12(Draw Plot Plan on Revers ide) <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I <br /> Application Accepted By <br /> O� _.. DateoZ <br /> Additional Comments: I <br /> Phase 11 Grout Inspection T as III Final Inspection <br /> Inspection By Date Inspection By 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by : Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95P' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES <br />