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TApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> _ rA (For Non-Transferable, Revocable, Suspendable) <br /> \5 ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) 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:ts <br /> made in compliance wl h San Joa uin County Ordinance No. 1862 and the rules and regulations of th Sa Joaquin Local Health Distric <br /> Exact Site Addresst blewnegi <br /> Owner's Name n lee Phone (� --,��7 <br /> Address City— 1L 1 Ute <br /> Contractor's Name License#_ cV0 Business Phone_ <br /> Contractor's Address mergency Phone L,%2 71 1 <br /> Is Certificate of Workman's Compensationnsurance 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 /> 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 /> *IRRIGATION X GRAVEL PACK Depth of Grout Seal /lOrlE' <br /> ❑ CATHODIC PROTECTION X ROTARY Type of Grout -.6�///lU/1e <br /> 11 DISPOSAL E] OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _ 01_ <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 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 /> 1 will all for a Grout Inpeg I n prior to gr uting and a final inspect' <br /> Signed X (_-!„+r'@ieleDate: <br /> (Dr Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI WY&, <br /> Application Accepted By Date <br /> Additional Comments: i <br /> Phase I1� ut Ilspection Ph a III Final Inspectiort� cc'� <br /> Inspection By to Inspection By _ Date �C "'i �� <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> l c 7 <br /> Received by Date Receipt No. Permit No. Is uance 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 />