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Applications Will Be Processed When Submitted Properly Completed._BeSureToSignTheApplication. <br /> 'FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f .� 6 <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 withDSa. Joa in ounty Or inan a No.X62 and tth rules and regulations of the San Joaquin Local Hie_ th District. <br /> Exact Site Address �.• 1�7. City/Town <br /> � + T. <br /> Owner's <br /> Name, p Phone r <br /> € YV <br /> Address r City <br /> Contractor's Namer d License# 74 Business Pho�le <br /> Contractor's Address� Vk Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> CNO <br /> TYPE OF WORK (CHECK): NEW WELL V' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ (� Q <br /> DISTANCE TO NEAREST: Septic Tank 1 S9vr=��s !� _� rivy <br /> iSewage Disposal Field 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 /> I❑ OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> RRIGATION ❑ GRAVEL PACK Depth of Grout Seal w.� C <br /> ❑ CATHODIC PROTECTION ❑�if]TARYn Type of Grout !yC�C tit Y <br /> ❑ DISPOSAL OTHER [( Q, Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. C <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> F 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 /> I <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:"!certify that in the performance of the work for which this <br /> permit is issued, I shal ploy p rsons subject to workman's compensation laws of California." <br /> I i all r a G t I t o to outing and a final in a ti / <br /> Signed X Title: CCA I& Date: L <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI Q <br /> Application Accepted By =— 't Date 7 <br /> Additional Comments: <br /> { Phase II Grout Inspection se III Fin spection <br /> Inspection By Date Inspection By�` haDate <br /> k <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 <br /> k BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE JAJ <br /> ' — <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4 F <br /> Received by Date Receipt No. Permit No. IsEkancb Date Mailed Delivered s ` <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 F <br />