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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> usE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br />71sCertificate <br /> ETE IN TRIPLICATE) WATER QUALITY <br /> tion 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 /> compliance with San Joaqu' ounty Ordinance No. 8 nd th� rand regulat' the Samoa )n�L,o/caall Health District. <br /> ite Address V ✓� f !" v Gown �, U cjel j�— /I cam} <br /> Na — Phone �{co <br /> City . c � AC' . <br /> tor's Name ense#�� Business Phone <br /> tor's Address Q mergency Phone A17-�— Q 2 9 y <br /> icate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 2' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9^PUMP REPAIR❑ <br /> REPLACEMENT❑ / ` [v <br /> DISTANCE TO NEAREST: Septic Tank {'— Sewer Lines �4 '- --- Pit Privy <br /> Sewage Disposal FieldCesspool/Seepage Pity' - Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INP,JUSTRIAL ❑ CABLE TOOL Dia. of Well Excavations <br /> OMESTIC/PRIVATE El DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing %Z <br /> ❑ IRRIGATION ❑ GEL PACK Depth of Grout Se O <br /> ❑ CATHODIC PROTECTION @3 ROTARY Type of Grout d/Ir .G AICI <br /> ❑ DISPOSAL ❑ OTHER Other Information /1 -�s/�� <br /> 11 GEOPHYSICAL urface Seal Installed Bye ivr�� ` <br /> PUMP INSTALLATION: Contractor AC-G <br /> Type of Pump 75r- <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 /> E <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 /> 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout I 7tr grouting and a final inspection. <br /> t /�M d <br /> Signed X Title: � I , Date: <br /> (Draw Plot Plan on Reverse Side) I I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted By GA © Date d` <br /> Additional Comments: <br /> p ��r t Inspection p II al I ection <br /> Inspection B Q� IAS Date Ins ection BV <br /> /at <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive By Ja u 31 Jy❑ my 1 R eceive By J y 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE at DATE REMITTED AMOUNT <br /> FEE IV # B O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ou <br /> Received by cfate Receipt No. Perms o. 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 />