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Applications Will Be Processed When Submitted Property CompteA*&, <br /> d:`hir Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTALHEALTHPERMIT <br /> (COMPLETE`IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin_Co/unty-Ord• ance No. 1862 and the rules and regulations of the San quin L al Health District. <br /> Exact Site Address City/Town pa oN <br /> Owner's Name C a Phone 7/ <br /> Address >; City, }o c) a J%J I <br /> Contractor's Name 0 mea License#-+�`7 � 0 8usinesii-Phone `tf'9'3 ;I <br /> Contractor's Address k 3 CS !aCA t'i'�e1ieJ�fi Emergency 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 I& OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 /> 0 INDUSTRIAL ❑ CABLE•TOOL, Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 0 .DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑'GRAVEL PACK Depth of Grout Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 0 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal.Installed By. <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump , <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP ❑ State Work Done r---- <br /> ESTRUCTION OF WELL Well Diameter Approimate De fh 8` t <br /> Describe Material and Pro edure +� I <br /> a aIL C <br /> � <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 o0ner or licensed agent's signature certifies the fol)awing:"I certify that in the performance of the work for which this permit <br /> is issued,,l shall.not employ any person in such manner as to become subject to workman's compensation taws 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 /> P4 si ued, l shell,employ persons subject to workman's compensation laws of California." <br /> ca or to and a'tinat inspection: <br /> Signed Title: Date: /67- /3Z -� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i y... <br /> r Date �� <br /> Application Accepted,B. , <br /> Additional Comments, <br /> Phase It Grout Inspection Phase ill Final Inspection <br /> Inspection By AV)0 Date Inspection By Delfe <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0 PER SITE 0 EACH 0 January 1"&Received By Jan 1 ❑July 1 &Received By July 31 <br /> REMIT`,: <br /> BASE EXPLANATION BILLING REMITTANCE S 'AMOUNT DUE CHECKED <br /> DATE OA TED, AMOUNT <br /> IEE "_ <br /> LESS <br /> PRORATION <br /> PLUS ` <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Datf Receipt No. Permit No. issuance Date Mailed Delivered- <br /> APPLICANT—RETURN <br /> el vered.APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA NW ° H <br />