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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 v <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 instal I the work herein described.This application is <br /> made in compliance with San Joaquin CountX Ordinan a No. 1862 and the r a d re ulations of the San Jyoquin Locjal�Health District. <br /> Exact Site Address�yl /�- �0 b �/} 4 Tif g City/Town <br /> Owner's Na a l%W74144..•� -�e� /��T Phone <br /> Address @ city �� <br /> Contractor's Name License# 7z_� Business PhoneGz. G <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fil With SJLHD? Yes 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" <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> A DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 11 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL .{ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor � <br /> Cul �GType of Pump ix H.P. Ar <br /> PUMP REPLACE NT: ❑ State Work Done �. <br /> PUMP REPAIR: ❑ State Work Done Q <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 /> I <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will 11 for a qiqu inspection prior to grouting and a final ins ion. <br /> Signed X Title: I ,t.�lt1-� Date: O a f <br /> (Draw Plot Plan on Revers Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 _ _ <br /> Application Accepted By � 'y - Date I <br /> Additional Comments: <br /> PMrout Inspection JPhase 111 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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 47 <br /> Received by Date Receipt No. Permit No. Issuance 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 />