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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR RWICE USE: APPLICATION <br /> mt (For Non-Transferable, Revocable, Suspendable) 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 incompliance with Saan"Joaquin County Ordinance No. 1862 and the rules and egulations of the San Joaquin Local Health District. <br /> Exact Site Address�T!* w. S..c,�e l=�jr.� !!.� o.L t.a�'�s��_4=0 City/Town <br /> Owner's Name Phone <br /> Address J g _ City c$ piG Contractor's Name Name ye,4-J License#1f37 w-Z— Business Phone 1 <br /> Contractor's Address 06 mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ D? Yes A — No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ FIECONDITION❑ DESTRUCTION❑ V , <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 <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 Install <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 60 State Work Done oN <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r1 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 GroutMisvecti(inxfl6rt routing a final inspection. <br /> Signed J4.� itie: 4te r bate: v <br /> (Draw Plo Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ` Date <br /> Additional Comments: <br /> Phase II Grout Inspection ^ReceivedBy <br /> Lingection <br /> Inspection By Date Inspectioate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 13 PER SITE ❑ EACH ❑ January 1y 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 O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 40 <br /> OTHER <br /> OTHER <br /> 30 <br /> Received by Date .,4 Receipt No. Permit No. tssuancWDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: y ENVIRONMENTAL HEALTH PERWTAWWA%CBS 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />