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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE-'USE: APPLICATION <br /> 1 0 (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH"PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY _ <br /> Application is hereby made to the San Joaquin Local HealthDistrict for a,permittoconstr ctand/or install the work herein described.This is <br /> made in compliance with San Joaquin County Ordinance No. t 62 egulations of the San Joaquin Local Health Dist <br /> and the rules and rrict. <br /> Exact Site Address ��` k 6 City/Town <br /> Owner's'Name �t : �•. .is trx,• fie Phone �. <br /> Address 4. _e.., <br /> City r- <br /> s <br /> Contractor's NameQr ilii r"'License#" 7.�>+,Business Phone <br /> Contractor's Address 1 Emei:geney Phone " • ' {Iqf>' "` <br /> �U <br /> Is Certificate of Workman's Compensation Insurance on t=ile Wi SJLHD? Yes No 4 <br /> TYPE OF WORK (CHECK): NEIN'WELL❑'�TDE�PEN ElRECONDITION❑' DESTRUCTION❑' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS <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 r <br /> INTENDED USE TYPE OF WELL <br /> x <br /> ❑ INDUSTRIAL ❑ CABLE TOOL pia. of Well Excavation <br /> 5( DOMESTIC/PRIVATE ❑ DRILLED 4 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 ❑ t <br /> OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> .. �, -,...`,.Type of Pump rr✓ H P <br /> PUMP REPLACEMENT:_ ❑ State Work Done <br /> PUMP REPAIR: ! ® State Work Done jl` r ' y C] <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth f <br /> . Describe-Material,,and Procedure <br /> _ - - <br /> I hereby certify that I have7prepared 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 forwhich this <br /> permit is issued, I shall employ'persons subject to workman's compensation laws of California." <br /> w I call for a Grout Inspection_prior O routi ad a final-inspection. <br /> Signed Itle: IkAi Date: /L-43 s <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By K2Date 3- r2-- <br /> Additional Comments: ' <br /> 6Phase 11 Grout Inspection Phase-III Final Inspection �� <br /> Inspection By Date Inspection By 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 /> j BASE EXPLANATION DATE DATE 'REMITTED AMOUNT DUE CHECKED <br /> q AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER- <br /> 1 <br /> „ V,51 <br /> Received by -Date-'h: M -Receipt No. - y' .,a Permit No..--:— _ - - I sua a Date Mailed Delivered <br /> r..w <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />