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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> #� (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRO HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) / L'_0,A Q"A N QUALITY <br /> Application is hereby made to the an Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in with San oaquin County Ordinance No./1862 and the <br /> "rules and reeggullat'i°g/r�of the San Joaquin Local Health District., <br /> Exact Site Address e #a) QV04� &4_A *yJ? fy/Town /,o?6 9,66 zyas-, -56 Ve-, /",*�[ <br /> Owner's Name9� Phone <br /> Address _ 10/1) (? 1b _ City `'m"__&ea <br /> Contractor's Name 44 License# �9d�13_ Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensationnsurance on File With SJLHD? Yes __X No <br /> TYPE OF WORK {CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 6' <br /> DISTANCE TO NEAREST: Septic Tank 75 Sewer Lines Pit Privy r <br /> Sewage Disposal Field 7S/+ 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 /> 06 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing / lid <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 <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call fora Grout In ection prior to grouting and a final inspection. f <br /> /z, <br /> Signed X Title: Date: a <br /> raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I g2 <br /> Application Accepted 10 Date <br /> I �?9 90 <br /> Additional Comments: <br /> Ph se 11 Grout Inspection Phase III Final Inspection <br /> Inspection By C Date \ — Inspection By Date ) r`50 <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 /> OTHE /� TT <br /> V A <br /> R eived 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 STOCK TON,CA 9 <br />