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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> 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 Joa um County Ord' a cue No. 1862 and the rules and regulations of the San J In L al ealth District. <br /> Exact Site Address o4 Fri`-11 Ir�i�n.V"3 - City/Town s <br /> Owner's Name 44-Z `�OAJ Phone <br /> Address / S City S <br /> Contractor's Name License# Business Phone Irc ^� 9 <br /> Contractor's Address 4 Emergency Phone -7/421- <br /> Is Certificate of Workman's Compensation Insurance on Fi a With S LHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL®" DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Er' PUMP REPAIR❑ <br /> REPLACEMENT❑ / e 'r <br /> DISTANCE TO NEAREST: Septic Tank L 4 Sewer Lines /6-0 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> a <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 /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout p <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL S rface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .A1_1-;"•-,6fP H.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 /> Home owner 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 /> ermit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will II&fGrput Inspecti , prior to grouting and a final inspe,�ti)on. r <br /> Title: ((yycc��1: Date: <br /> Signed X �- — -� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date 1 <br /> Additional Comments: <br /> Phase ILSrout Inspection a Phase Ill Final Inspection g <br /> Inspection By Date �����l Inspection By Date �� 7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT la PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> — eT/�(7y 79 -I0 5se `1 .-� <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 STOCKTON,CA 9501 _ <br />