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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR{OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) I D l Jv A�Rvtf WATER QUALITY kjr <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 o uinCounty Ordi an No. 1862 and the rules and regulations of the San�o��agq�ulj��n/L I Heath District. <br /> Exact Site Address City/Town (N X n <br /> Owner's Name f1 e C Phone r <br /> Address h'l _ City ZIAO N �S d I <br /> Contractor's Name License#�;S�n Business hone _�7`— a7 7 <br /> t <br /> Contractor's Address x Emergency Phone "Sqi <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL X DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION UK PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank A&Uf Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/S&epage Pit Other <br /> Property Line3�Private Domestic Well ®�Q Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ `CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE U, A DRILLED Dia. of Well Casing ISL r`$$ <br /> ❑ DOMESTIC/PUB ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 4 ~ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL 'aur ace Seal Installed By: <br /> PUMP INSTALLATION: Contractors: <br /> Type of P,6i ip 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 /> Y <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 ca I four ja Grout)ns ection prioLto grouting and a final inspection. <br /> Signed X /� l�tf?JufZoTitle: � �r— A ei. Date: �4& <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE t <br /> Application AcceptBy Date <br /> Additional Comme <br /> as t 11 Grout Inspection ��j J19ale III 6i I ction <br /> Inspectio By Date �r VL nspection By �1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> ILLING EM TANCE $ <br /> BASE EXPLANATION DATE TE REMITTED AMOUNT DUE CHECKED <br /> Jk <br /> AMOUNT <br /> FEE �Q ' ffti <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. IssuaInce D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />