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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> v- (For Non-Transferable, Revocable,Suspendable) <br /> 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 is <br /> made in compliance Cwith San Joaquin oun y Ordinanc' ND. 1862 the rui and r ulations of the San J q In Local eal h District. <br /> Exact Site Address `f ✓< <Q LI1r �de. City/Town gXe C ��1 <br /> Owner's Name , f Phone f31—Z9 5 Q 3 <br /> Address 5 City 5el< 7! l6 <br /> Contractor's Name _ License# / 313usiness Phone <br /> Contractor's Address �/�110 L. 4e L-r e 60— Emergency Phone <br /> k <br /> Is Certificate of.Workman's Compensation Insurance on File With SJLHD? Yes 4 No _ <br /> TYPE OF WORK (CHECK): NEW WELLN DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank /®� Sewer Lines ��_Q_f 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 !7 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> �p <br /> DOMESTIC/PRIVATE �4DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ✓� <br /> r ❑ CATHODIC PROTECTION ROTARY Type of Grouter�9 ���� 124e <br /> ❑ DISPOSAL ❑ OTHER Other Information r <br /> i ❑ GEOPHYSICAL ��r// S&ce Seal Installed By: <br /> PUMP INSTALLATION: Contractor ✓1/��L 115, ;Iol <br /> t <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 emWo <br /> persons subject to workman's compensation laws of California." <br /> 1 <br /> will r a ut In n grouting.-and a final inspect" r <br /> Signed X Title: Date: L� j '- <br /> (Draw Plot Plan on Reverse Sid <br /> Ze <br /> ORD PARTME T.USE ONLY <br /> PHASE I ti" , <br /> Application Accepted By r "'� Date <br /> Additional Comments: 449 <br /> Xhase 11 Grout Inspection -7e III 'n I Inspection <br /> Inspection By Date I r —�� inspection By .In@atee C) <br /> ► Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH '❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i BILLING REMITTANCE $ REMIT <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATSON DATE DATE REMITTED <br /> AMOUNT <br /> i <br /> FEE <br /> LESS �1 <br /> t PRORATION <br /> E <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> n, Received by Date Receipt No. Perms o. - 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 <br />