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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 1= R OFFICE USE: APPLICATIM <br /> _4W_ " (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 with San Joaquin C n y Ordinance No. 1862 and a rules and regulations of the San aq i� Local He Ith District. <br /> Exact Site Address CP � �/� `� City/Town C)C_ Ar C ' W <br /> Owner's Name Q 00 Ar C C) . Phone <br /> Address O c�-foil/' Gq- 9 S,2/ U) <br /> Contractor's Nam u /NC`License# Business <br /> Phone <br /> Contractor's Address a� — O 45_ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL C-- 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 �/ D <br /> ❑ INQUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 5 x <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION TARY Type of Grout A,-C, <br /> ❑ DISPOSAL ❑ OTHER Other.Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By:` ' • A /.V G <br /> PUMP INSTALLATION: Contractor <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will call for a GroutMi, rl r grouting and a final inspection. <br /> Signed X Title: G�'"9;_�• Cv� Qno n • Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHA <br /> /] ' / F i` Date �U <br /> Application Acceptec4v - <br /> i' <br /> Additional Comm nts: <br /> Phas II Grout Inspectio Ph se III Final Inspection <br /> Inspection By ate fT� Inspection y Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> (� AMOUNT <br /> FEE �jp� j�A(e� �—/— � :�—7 80 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - <br /> /fWceived 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 />