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Applications Will Be Processed When Submitted Propeft Completed. Be Sure To Sign The Application. <br /> FOR OFWCE USE: APPLICATION <br /> com,p10,04P/k, (For Non-Transferable,Revocable,Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT c <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 Ordi Rance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address hart.1 p l-�A,4C 1:te 07"w- 'frtie l City/Town <br /> Owner's Name Phone <br /> Address SX— City— <br /> Contractor's <br /> ity Contractor's Name W License#1913 7"--Business.Phone 4LL'Y —?.07-4 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ HD? Yes )e No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR <br /> REPLACEMENT❑ v <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 /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL > Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor4 <br /> Type of PumpH.P. / ry <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP IRSPOOR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Xpproximate 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Ins pe t, pr 'groom ,g and final inspection. <br /> Signed Xitle: �r'�..lam^ Date: 3 / <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI _ p <br /> Application Accepted By "n �` --i � r j CI-01;31 Date o J <br /> Additional Comments: <br /> Phase)[Grout Inspection AMP <br /> / //gra 1!I F'nal Inspection <br /> Inspection By ��� Date 1 Inspection By '`z 711 Date �� Sy��S <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Isstiance 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 />