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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: s APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> \0 , ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address - e���S /' kf 2[ S City/Town SC4_10Xi <br /> Owner's Name RA v �j1r��rJ Phone <br /> Address ` C £ City Y q) <br /> Contractor's Name + License a7fllV Business Phoner- <br /> Contractor's Address Q/3 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes� No _ <br /> TYPE OF WORK (CHECK): NEW WELL M, DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank .5'99 r4 Sewer Lines d �{ Pit Privy — <br /> Sewage Disposal,Field /0014 Cessp000I/Seepage Pit �.---- Other _ <br /> Property LineA.Private Domestic Well Public Domestic Well �-----T <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> A,DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <e f <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: OWAt c <br /> PUMP INSTALLATION: Contractor `� E <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: -R --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-contractirosignature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall mplo rr1C <br /> ons subject to workman's compensation laws of California." <br /> I all f a rout spec r to groutin nd a final inspection. ,L-- <br /> Signed X Title: ^� ` Date: <br /> (Draw Plot Plan on Reven6 Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I C <br /> Application AcceptBy Date <br /> Additional Comme, <br /> ��9 <br /> ?!"Out rout Inspection se III Final Inspection <br /> Inspection By ate —2 `:� Inspection By Date <br /> i <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 /> Received by Date Receipt No. Permit No. - Isguancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601_E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520N� <br />