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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION ( L <br /> c — <br /> IFor NQQ-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 with San J aquin Count Ordin e No. 1862 and the rules and regulations of the San Joaquin L c I Health District. <br /> Exact Site Address City/Towne �o <br /> Owner's Name � 1s •�2 � ��� Phone <br /> Address City <br /> Contractor's Name License 4 !9 Business Phone <br /> Contractor's Address it /. 3 .fir_%rE Air- Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN, RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ e 0� Sewer Lines �� .4- Pit Privy <br /> Sewage Disposal Field .100 �A Cesspool/Seepage Pit Other <br /> Property Line/0_.+_ Private Domestic Well _ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation � ,E � �iNo 1& �o c <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casingp�fErJjtyc Ger 1.6 �` C�'l.Cae <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ �/ ®er le /1j441,F r' <br /> K IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout /� <br /> ❑ DISPOSAL 1-1OTHEROther Information 00X04- -- - -caari......!g <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump 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 m� <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, , hal empl ersons subject to workman's compensation laws of California." <br /> I call fora o in SP If prior to grouting and a final inspection. <br /> Signed X Title: .tr Al T'-- Dater <br /> Draw Plot Plan on Reve Side <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 -1- <br /> Application Accepted By C• / Date S 9 <br /> Additional Comments: <br /> Phase II Grout Inspection P lase III Final InspIection <br /> Inspection By Date Inspection B Date <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> u F tri' <br /> FEE J� -00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. r lesuarice Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />