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Applications Will Be Processed When Submitted P : pleted. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APDL I0N <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is a <br /> made in compliance wilh San J uin County Ordin nce o. 1862 and the rules and regulations of the San Joaq Local Health District. I <br /> Exact Site Address s 15 o 'C. Ak" A( City/Town i ✓Jio�,r UA <br /> r� Ui <br /> Owner's Name /L Phone��! !7 ( v <br /> Address City— -��� � <br /> Contractor's Namezv icense fkL �1/� Business Phone <br /> Contractor's Address Emergency Phone Q '.2 klb <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X 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 <br /> ther_Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL l t, <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 A GRAVEL PACK Depth of Grout Seal t�U lW <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout C ✓.�Ene o„ <br /> ❑ DISPOSAL ❑ OTHER Other Information I V <br /> ❑ GEOPHYSICAL Surface Seal Installed By: cY r`/r <br /> PUMP INSTALLATION: Contractor U <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 pers ns subject to workman's compensation laws of California." <br /> I will Sjll4or a Gro ns actio ° or to grouting and a final inspection. <br /> � 1 <br /> Signed X Title: Date': ,? � �an/L <br /> (Draw Plot Plan on Reverse Ie) <br /> FOR DEPART ENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By Date �U�' �a <br /> Additional Comments: <br /> P ase 11 out Inspection' Phase III Final Inspection <br /> Inspection By ` Date/� "rte Inspection By _ Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT IrPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 3 `� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> f <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 952 <br />