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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> V, /5 me Pk (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> G II" ENVIRONMENTAL HEALTH PERMIT <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.1862 and the rules and r 41ati—nisof the San Joaquin Local Health District. <br /> Exact Site Address tcea <br /> } own <br /> Owner's Name L0 J 10. C- Phone <br /> Address Ih^ , City 1.04 p <br /> Contractor's Name l License# )913 7xrbusiness Phone L f `74 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on file With S HD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1W <br /> REPLACEMENT❑ j <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage 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 /> 90 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 1 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL �+1 ' Surface Seal Ins I y <br /> PUMP INSTALLATION: Contractor 5 � r <br /> Type of Pump I M.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 /> 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 wo kman's compensation laws of California." <br /> I will fall for a Grout Inspectio rt o ting a fin I ' pection. <br /> Signed <br /> Date: <br /> (Draw Plot Plan o Reverse Side) <br /> PHASEI FOR DEPARTMENT USE ONLY <br /> Application Accepted y Date " <br /> Additional Commen 2� <br /> Phase II Grout Inspection Phase RI Final Inspection <br /> Inspection By Date Inspection By 1// Date —� <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar ❑ ulJ y i &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> EFEE 445 <br /> ON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. l9suande Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />