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dons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL O <br /> ENVIRONMENTAL HEALTH PERMIT - 1 <br /> ` , WATER QUALITY <br /> (CO IN TRIPLICATE) llr hyt�CLI <br /> Application is hereby made tethe San Joaquin Local HealthIs rictforapermittoconstructand/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 Sa Joaquin Local Health District. <br /> Exact Site Address ,07 <br /> :50 le, �� ���Nw� City/Town �g <br /> Owner's Name _ _ Phone <br /> Address t'x An City sap &� <br /> Contractor's Name Ml tIf� b46 �11�1 License# Ih Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ 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 /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 4 ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE. ,, ❑ DSILLED Dia. of Well Casing <br /> i ❑ DOMESTIC/PUBLIC ❑DRIVEN Gauge of Casing <br /> " IRRIGATION" X n --0_❑ GRAVEL PACs( - Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 31 ❑,ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance Of the work forwhich 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 /> I will call f a Grout fnspecti p ' r to grotjing and a final inspection. <� <br /> t f <br /> Signed X Title: Ct� � Date:. ef 7 17..,__.__.. <br /> (Draw Plot Plan on Reve se Side) <br /> FORD PART ME T USE ONLY <br /> PHASE I � f7 <br /> Application Accepted By "' la Date d <br /> Additional Comments: <br /> n,. <br /> Phase II Grout Inspection Phase III Final Inspections-Cry <br /> Inspection By _ Date Inspection By Date ` <br /> Fee IS Due: ❑ ANNUALLY ❑ PER LINT Rr PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION 4p TE 'DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS ' <br /> PRORATION <br /> PLUS s <br /> PENALTY a <br /> OTHER <br /> OTHER `' T <br /> t, <br /> f- <br /> j Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 'a r b JI 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />