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NWwizzionswill BeProcessedWhen Submitted Properly Completed.B gore To Sign The Application. <br /> [FOR OFFICE USE: APPLICATION <br /> �� <br /> (For Non-Transferable, Revocable, Suspendable) w �� <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San J�aquln(5ou t Ordinance No. 1862 anthe rules and regulations of the San Joa uin ocal Health District. <br /> Exact Site Address �gaa�} �� '� , <br /> =-10U�-p, City/Town (V �� <br /> Owner's Name t !U <br /> Address � Q I$l? Phone —A 33G` <br /> Contractor's Name Cfq City .�C # <br /> �.t- ense# t' <br /> Contractor's Address 2 eja G�'6� (� Business Phone, <br /> Is Certificate of Workman's Compensation Insurance on Fi a With SJLHD? <br /> Emergency Phone o <br /> Yes t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ No <br /> WELL CHLORINATION ❑ RECONDITION❑ DESTRUCTION❑ r <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ / y <br /> REPLACEMENT❑ _ PUMP REPAIR" <br /> DISTANCE TO NEAREST: Septic Tank ' 4 Sal / r A <br /> we Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit ' <br /> Property Line Private Domestic Well Other <br /> INTENDED USE � Public Domestic Well (,1, <br /> ❑ INDUSTRIALTYPE OF WELL <br /> ❑ DOMESTIC/PRIVATE ❑ CABLE TOOL Dia. of Well Excavation <br /> �- �,t © DRILLED <br /> ❑ DOMESTIC/PUBLIC Dia. of Well Casing <br /> 11 IRRIGATION ❑ DRIVEN Gauge of Casing 1 <br /> CJ CATHODIC PROTECTION O GRAVEL PACK Depth of Grout Seal F <br /> ❑ DISPOSAL w ROTARY Type of Grout <br /> ❑ GEOPHYSICAL ❑ OTHER Other Information <br /> PUMP INSTALLATION: Contras#or Surface Seal Installed By: <br /> _.� <br /> 1 • '- Type of Pump H.P. <br /> PUMP REPLACEMENT: a. ❑ State Work Done <br /> PUMP REPAIR: L P <br /> State Work pone L t <br /> DESTRUCTION OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 /> Horne 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 for which this <br /> permit is issued, ! shall employ persons subject to workman's compensation laws of California." <br /> I amitt — <br /> g and a final inspection. <br /> Signed X � <br /> Title: Date: { <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE [ <br /> Application Accepted By �� <br /> Additional Comments: Date�g'2 <br /> Phase fl rout Inspection <br /> Inspection By Date Phase til Final Inspection <br /> Inspection By Date $ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 8 Received ay January 31 El July 1 &Received By Jufy 31 <br /> BASE EXPLANATION BILLING _ REMITTANCE REMIT <br /> DATE DATE REMTTED AMOUNT DUE CHECKED . <br /> FEE �r ° AMOUNT <br /> LESS <br /> a <br /> PRORATION - <br /> PLUS 1;� <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> G lZ S <br /> Received by Date n <br /> Receipt No. Permit No Issuance Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESMailed Delivered <br /> 1601 E.HAZELTON AVE,,P.O.Box 2099 STOCKTON,CA 95201 <br />