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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 /> C } {�1JtJ PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with Sa Joaquin C my rdinance N . 1862 and the rules and regulations of the San�qJoaquin Local Health District. <br /> Exact Site Address 1#1113 City/Town &—&&a <br /> Owner's Name ! Phone 213114_ 4908 <br /> Address ity <br /> ' ,( 23 f <br /> Contractor's Name License#2&6&�� & Business Phone � <br /> Contractor's Address r1—1304W&,m Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L/ 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 /> ❑,/}NDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> y�DOMESTIC/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 �T����� Sur_face Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump J- H.P.I <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ISI State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 G Inspection prior to grouting and a final inspect' <br /> Signed X ��-"+rte= Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> d � <br /> Application Accepted By ` -J Date <br /> Additional Comments: <br /> Phase II Grout Inspection ` Phase III Final Inspection <br /> Inspection By Date Inspection By 1 Date U_S–'E <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 AMOUNT DUE CHECKED <br /> 00 1 DATE DATE REMITTED <br /> AMOUNT <br /> FEE s qJ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 73 <br /> ' <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 23 <br />