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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> TR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL. <br /> �� ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto constructand/or install thework herein described.This application is <br /> made in compliance with Joa in un ty Ordinance No. 1862 and the rules and regulations of the San Jo iI� Ialth District. <br /> Exact Site Address �. City/Town <br /> Owner's NameAk� Phone. - 7— <br /> Address Q City <br /> Contractor's Name CLI4& uzLI, !1 License#76416 Z Business Phone <br /> Contractor's Address w Emergency Phone +� �Z-6 <br /> Is Certificate of Workman's Compensation I�nsur2an won 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❑ s ,,`` i <br /> DISTANCE TO NEAREST: Septic Tank �QU <br /> Sewer Lines Pit Privy <br /> t <br /> Sewage Disposal Field 160 �^ Cessp000ll//Steeeepage Pit Other <br /> Property Line 15" Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IKPeSTRIAL -- ❑ CABLE TOOL Dia. of Well Excavation l� d <br /> r <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing NAP.12 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ��- <br /> ❑ IRRIGATION ;'ROTArRY <br /> PACK Depth of Grout Seal, <br /> ❑ CATHODIC PROTECTION Type of Grout trvr0/V/T <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in-the performance of the work for wHieb this permit <br /> is issued, I shall-scot 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 /> rmit is issue , I shall employ persons subject to workman's compensation laws of California." <br /> I w 11 GroM spection prior to grouting and a final inspection. <br /> Signed X � Title: Wllat K - Date: SEP <br /> SEP <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE.O LY <br /> PHASEI <br /> Application Accepted By /9Date I.T Sex, 79' <br /> Additional Comments: <br /> ,,Phasel Grout Inspection ' h II nal Inspectionq 1 <br /> Inspection By _ Date \ -17 ` Inspection By Date `� 11�� <br /> r <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT I PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> j 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. 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 />