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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) <br /> PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY J--bT' to <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance wiT San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address CO3S� ANT City/Town lU <br /> Owner's Name iJj Phone <br /> Address City <br /> Contractor's Name License#3"471 Business Phone -�— r <br /> Contractor's Address R 01 Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File ith SJLHD? Yes_�� No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ S <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR El l <br /> r <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ,r <br /> Sewage Disposal Field Cesspool/Seepage Pit Other d <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 of Casing <br /> i ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal U� . <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout (� <br /> Ik ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Contactor Er'7".4-s hV LQ <br /> Type of Pump I H.P. aP/ <br /> PUMP REPLACEMENT: ❑ State Work Done Of <br /> E 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 Ile 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 thatI the performance of the work forwhich this permit <br /> is issued, I shall not employ any person in such manner as to become subje to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certif. that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation;aws of California." <br /> ---d-will call: rout-h�spection.priorlto grouting and-a f al j5pectpn. <br /> i <br /> Signed e Title: cy+�e.`� Date: 9—2—'Z 7 g <br /> (Draw Plot Plan on Reverse Side) <br /> � FPR DEP-RTM� ENT SE ONLY <br /> PHASE j <br /> Application Ac epted By Date <br /> Additional CAments: 7NI, <br /> � N <br /> V <br /> Phase II.Gr_1ul Inspeclion Phase III Final Inspection <br /> �S.Duze%n <br /> nspeuo�r, y Date Inspec ion Bty, Date <br /> Fee NNUALLY i' PER,u iT PER SITE ❑ EACH ❑ Janua y 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANC $ <br /> /i BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEENJ` �`` �g AMOUNT <br /> V� i! �� C� <br /> LESS TIO I <br /> PRORATION I <br /> PLUS 4& <br /> PEN ]�,"� <br /> ALTY �r � <br /> OTHER r ! t' ' <br /> r ' i <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO> ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTO CA 52 <br />