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Applications Wille-Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR OFFICE.U$E: / APPLICAtION <br /> 601^'-�r3���° (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ....� <br /> . <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> ' 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 Ordina�/nce No..�1 62 and the rules and r gula Ions of the San Joaquin Local Health District. <br /> Exact Site Address— F/y /�'I 1�" fid ►" ity/Town -- <br /> Owner's Name v r _ Phone_ <br /> Address OD _ City Ae r'A•.,/ <br /> a <br /> Contractor's Name S4-*%),y, ofu-.xab, License# 7� Business Phone <br /> Contractor's Address 'Mago&. (__Jr Emergency Phone -Is Certificate of Workman's Compensation Insurance on File With SJL, D? Yes_y___ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 01 <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 <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: D9 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." Saos�lpG� 3/2 <br /> I wal or a Grou Ins ection o g, nd a ' al ipspect' <br /> Date: <br /> Signed X <br /> raw Plot Plan on Rever Side) <br /> OR EPARTMENT USE ONLY <br /> PHASEIXO <br /> Application Accepted By ^�"" Date <br /> ley <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS t <br /> PRORATION <br /> PLUS ,. .. <br /> PENALTY ✓ `� <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I sua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />