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pplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION J <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is� <br /> made in compliance with`Sa�Jo quin County Or finance No. 1862 and the rules and regulations of the San Joaquin L9cal Health District. <br /> Exact Site Address �'�( � ►. Orf City/Town <br /> Owner's Name ( dt t/• �e r GrC?� Phone <br /> Address '504-AAB city- <br /> Contractor's <br /> ity Contractor's Name cone�c D/^! 41 Co, , License#17 2 28 Business Phone_ 3-5­4/3 <br /> Contractor's Address PO. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A' No <br /> TYPE OF WORK (CHECK): NEW WELL W DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _AnZ 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 /> t❑INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> .Icr DOMESTIC/PRIVATE 2-DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �G C <br /> ❑ IRRIGATION ® GRAVEL PACK Depth of Grout Seal S0� �t <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout L"eo, <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: toy-"C <br /> r <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 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 call for a rout In ppection�prior to grouting and a final inspection. <br /> Signed X (� -L !✓ Title: ��V���✓ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1.rG! <br /> Application Accepted By Date %2 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> Inspection By 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 AMOUNT <br /> FEE Y,3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ', s <br /> OTHER z <br /> OTHER <br /> �79-)t 53 1 p/4, <br /> Received by Date Receipt No. Permit No. Issuance Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 1,V014 lv-1A-79 QS <br />