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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheAppllcauon. " <br /> _ZICE APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> f. <br /> Application is hereby madetotheSan Joaquili Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance Nod 1862 and the rules and regulations of the San fquinL�l Health District. <br /> Exact Site Address 9� dt City/Town <br /> Owner's Name C e_ U C• Phone �Z-— d <br /> Address i'S -- -- City 512 <br /> j <br /> Contractor's Name License#.4 61 Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insura ce on File With SJLHD?- Yes Z— No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ' > <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT-99I 1 f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Cesspool/Seepage Pit Other 1 <br /> Sewage Disposal Meld <br /> ` � <br />' Property Line 14 Private Domestic Well_ Public Domestic Well II <br /> f INTENDED USE TYPE OF WELL k <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> e'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br />` ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION G <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of GroutI <br /> ❑ DISPOSAL ❑ OTHER Other Information 'V <br /> 13 GEOPHYSICAL Surface Seal Installed By: /\ k <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: M State Work Done v <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure a" <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 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 for a Grout Inspection ' r to grouting nd a final inspe n. <br /> Signed X Title: Date: t' r <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> . PHASE 1Date 38 <br /> Application Accepted By <br /> I Additional Comments: <br /> Phase 11 Grout Inspection hase l Final Inspectio <br /> l Inspection By Date Inspection Veceived <br /> Date <br /> Fee IS DUe: ❑'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & By January 31- ❑ July 1 &Received BylTuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 6:5 <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> { OTHER <br /> OTHER <br /> s <br /> Received by Date Receipt No. Perm9[No. �suance ate Mailed Delivered <br /> '1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 9520 <br /> APPLICANT—RETURN ALL COPIES TO:-,ENVIRONMENTAL HEALTH PERMITISERVICES <br />