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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,FOR OFFICE USE: APPLICATION JC4 <br /> qt (For Non-Transferable, Revocable, Suspendable) f <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto constructand/or install thework herein described.This application is <br /> made in compliance wiffh San Joaquin County Ordinance No. 1862 d the rules <br /> fand regulations of the San Joaquin Local Health District. <br /> Exact Site Address ` �L�-ltilG ,tt al V I(I k +'w��'r" �`City/Town <br /> Owner's Name �Qr�G � ; / Phone <br /> Address �G / R !� ( Den City C1e70)- <br /> Contractor's Name NCO c , License#:T Business Phone !Fly <br /> Contractor's AddressEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File 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 ❑ 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 C <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth aix <br /> '--" <br /> Describe Material a d Procedure l <br /> r (' <br /> I hereby certify that I have prepared this application and that the work will be done in acco dance with San Jo quin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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 /> permi is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t <br /> I wil call for a Grout Inspe Ibn <br /> rfor to grouting and a final inspe to <br /> _ > <br /> Signed XTitle: ---14 e—, a Date: <br /> (Draw Plot Plan on Reverse Si ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` C/ <br /> Application Accepted By Date p0 2� 7f <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase 111 Final Inspection 4 <br /> Inspection By Date y Inspection By \.LZI 1, 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 /> 749_11g1 -7w <br /> Received by Date Receipt No. Permif 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 />