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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: I j / APPLICATION <br /> (o k p `O Q (For Non-Transferable, Revocable,Suspendable) <br /> PUMP WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) E WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County 9rdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address R - p /y 4e:' City/Town ZR <br /> Owner's Name DG&lN -e -90 a *--t- Phone <br /> Address S? aSL Hldv' City— <br /> Contractor's <br /> ity Contractor's Name / .? s « License#1! 3-71J Business Phone <br /> Contractor's Address 'e�[?'.1 G Z6400 h0d4 1_ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With S LHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ d <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 /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> RrDOMESTIC/PRIVATE ❑ DRILLED 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 ❑ OTHER _ Other Information _ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ` -m <br /> Type of Pumper r . H.P. _ / Y' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP�R20m: State Work Done TEaCp4.,// A(4 AC2 <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 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 for which this <br /> permit is issued, I shall employ persons sub' to workman's compensation laws of California." <br /> I voll call for a Grout Inspect! p 'o group, g d final inspection. <br /> SignedDate: <br /> (Draw Plo Ian on Reverse Side) t <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE d <br /> Application Accepted By Date o 7/ <br /> Additional Comments: <br /> Phase II Grout Inspection Phase IIin nspection <br /> Inspection By 1rA IA 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED d, AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7.� <br /> 71—)ci�too <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.Boz 2009 STOCKTON,CA 95201 <br />