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Applications Will Be Processed When Submitted Properly Completed. re�� Aig�4heApplicaTion <br /> 6FICE USE: APPLICATION "`` <br /> (For Non-Transferable, Revocable,Suspendabl) g ��8� <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SAS,; <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY `r�� ql E H DI s'D-CT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install tework herein described.This application is <br /> made in compliance with San Joa uin C unty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address )rj 2 c' City/Town <br /> 423—T92-6 <br /> ���E-.&e <br /> ' <br /> Owner's Name U +" Phone 423—T 9 2-6 OS <br /> Address -A City YY26, <br /> Contractor's Name S{ License#'2p&C k Business Phone_ <br /> Contractor's Address __, - ���i a�'3�Q.� Q= Emergency Phone ` <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes C/ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRO <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 v <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A,zit <br /> Type of Pumply� H.P. <br /> PUMP REPLACEMENT: State Work Done4 &' �-c , � d. 'L�c -s'i- <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." C,4, <br /> I will call for as Grout Inspection prior to grouting and a final inspecti <br /> Signed X (;,J �-°- -t "----- , <br /> Title: .E'rwA Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPART ENT USE ONLY <br /> PHASE <br /> Application Accepted By ©� _ Date 2 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Dateeq Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT qU PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> .AMOUNT <br /> FEE It �_5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 �3 d 5a <br /> Received by ate 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 />