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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) 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 in compliance with San Joaquin County Ordinance No. 1862 and he rules and Segulations of the San Joaquin Local Health District. <br /> Exact Site Address s - ailee, ,P &ZvZ,.n .. e!e JWih City/Town <br /> Owner's Name PW 6'° tB` ROL04 C Al Phone <br /> Address dF 'F.; 444, &nm"4 moor City— <br /> if <br /> ity GR <br /> Contractor's Name Z�+ (License# Business Phone <br /> Contractor's Address 2 o AkEmergency Phone <br /> J <br /> Is Certificate of Workman's Compensation Insurance on File Wit LHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 19 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 /> 0 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 13,-OTHER Other Information <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 <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, I shall employ persons subject to workman's compensation laws of California." <br /> I III call for a Grout Ins n rio o outing and final inspecttiion. <br /> Signed life: Date: f " <br /> 61 (Draw P Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (�O`- <br /> Application Accepted By \ Date ti!' <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By \o Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jan 1 ❑ July 1&Received By July 31 <br /> ,i REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT OUE J CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> .FEE ' <br /> LESPRO ,- <br /> PRORATION <br /> PLUS h/ ✓✓� <br /> PENALTY <br /> OTHER ) CC <br /> OTHER <br /> l ; O <br /> Received by Date Receipt No. Permit No. IssuainceDate I I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />