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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.W, <br /> WOFFICE USE: APPLICATION <br /> 4"6.-xJo Jm ;a4�C (For Non-Transferable, Revocable, Suspendable) ^� <br /> ' ENVIRONMENTAL HEALTH PERMIT PUMP&WELL j <br /> W <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY nj <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 J aquin County Ordinance No. 1862 and the rules and r gu�latfions of the San Joaquin L Health District. <br /> Exact Site Address !t/ �n A.1 4:0 r N o /y s dL �"�City/Town d c'J'�"� <br /> Owner's Name 77-bot t9 C1 H 4p 6 Phone <br /> Address /8' �• E3!/ t!/ City <br /> Contractor's Name AI6 /r c License#_11%ii?-715 Business Phone_ ��� tea <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes __y 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 _ 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 S <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation c• <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: Contractor <br /> Type of Pump H.P. to-Ci <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 9 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." S <br /> Contractor's hiring or sub-contracting signature certifies the following:"J-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 /> 1 will call for a Grout Insp onfor uting ang a final inspection. <br /> Signed ) Title: ' Date: /& A" <br /> (Draw F416t Plan on Reverse Side) <br /> OR DE ARTMENT USE ONLY <br /> PHASE q <br /> Application Accepted By ''� �� Date Z 7` <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTH R <br /> OTHER <br /> 1771 L)CA <br />` Received by Date Receipt No. Perm t No. 'ssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,Cl 9 <br />