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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> t <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transfe'rable,'Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTFI PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY a <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 /> ' J•41; <br /> made in compliance with San Joaquin_ County Ordinance No. 1862 and the rules and regulationsuin,of the San Joa Local Health District. I, <br /> Exact Site Address G fw, a <br /> City/Town <br /> Owner's Name a i'Ir 4 �i as u r. <br /> ` Phone <br /> Address d ri, rY' )# -fry r City' <br /> Contractor's Name Ir License#L9_ .`Bu'siness Phone -7 7 <br /> i Contractor's Address a Eniergency`Phone <br /> Is Certificate of Workman's Compensat ra` c onMi -With ll HD? Yes No <br /> TYPE OF WORK (CHECK): 'NEW WELL❑ DEEPEN ❑ . RECONDITION❑ 'DESTRUCTION❑ — - y' <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 ''' l-Cesspool/Seepage Pit Other y <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 /> 9 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:' t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump_ W.P. <br /> PUMP REPLACEMENT: ❑ State Work Done # i <br /> PUMP REPAIR: ❑ State Work'Done 9 +- <br /> DESTRUCTION OF WELL: <br /> "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 Sari Joaquin Local Health District. €♦'a'— #� <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit i <br /> is issued, I shall not employ any person in such manner as to become subject to work man's'Compensat ion 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 work man's'corripensation laws of California.";" <br /> I will call for a Grout I p eti n p Br o outing and final inspection: _} l' <br /> i <br /> Signed itle: Date: <br /> (Draw Plo Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE I <br /> Application Accepted By —' "'�`✓-.._ I Date <br /> Additional Comments: } <br /> Phase It Grout inspection P s III FInaI Inspection f <br /> Inspection By 1 rk Date Inspection By- ' Date .Z —22`F 1 <br /> Fee,Is Due: ❑ ANNUALLY 11 PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jury 1 &Received By JUly 31 <br /> BILLING REMITTANCE- - REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION –# <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> - Received by Date Receipt No: Permit No - -.Issuante Date 1. Mailed Delivered <br /> _APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />