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AppitcatlansWillBeProcessed When Submitted Properly Completed. Be Sure To Sign_ The Application <br /> FOR OFFICE usr : [� pl APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> � PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> ' Application isherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and re Mations of the San Joaquin Local Health District. <br /> Exact Site Address i��t[��C c_ , i�6 J,� <br /> k a City/Town <br /> Owner's Name r <br /> Address &6 / Phone <br /> City <br /> Contractor's Name "�y�e-aJ�.,L/ w�. ,�'=,j License# l 2�� <br /> ty�_7 Business Phone <br /> r Contractor's Address Ad a Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi h SJLHD? Yes 1/ <br /> TYPE OF WORK (CHECK); NEW WELL 13DEEPEN 11RECONDITION 1:1 DESTRUCTION <br /> REPLACEMENT❑ ❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ElOTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> .. . <br /> i DISTANCE TO NEAREST: Septic TankSewer Line_si " + <br /> Pit Privy --- <br /> Sewage Disposal Field Cesspool/Seepage Pit _ `Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE E3 4 <br /> DRILLED Dia. of Well Casing ) <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> Gauge of Casing <br /> P3 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ' <br />! ❑ CATHODIC PROTECTION ❑.ROTARY <br /> ❑ DISPOSAL Type of Grout <br />` ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ) <br /> PUMP INSTALLATION: Contractor Loll- <br /> Type <br /> — <br /> , <br /> TYpe of Pump-- �" .��* ✓ �. H.P. <br /> � <br /> PUMP REPLACEMENT: El State Work Done ' <br /> PUMP REPAIR: ® t <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth b ; <br /> h _ Describe Material and Procedure t <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 /> IwI call for a Grout Inspecti ri t _ ro Ing and a final inspection. <br /> Signed XSl A,.i <br /> iBe: Date: ' <br /> {Draw Plo Plan on Reverse Side) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 ' <br /> Application Accepted By <br /> Additional Comments: Date <br /> Phase II Grout Inspection <br /> ,;. <br /> r <br /> Fnal Inspection t,Inspection By,. - � Ph i <br /> Date Inspection By Date Y <br /> Fee Is Due: A LLY ❑ PER UNIT ❑ PER SITE El EACH <br /> -WI - - r.'. ❑ January 1 &Received By January 31 EJ July 1 &Received By July 31 <br /> • BA EXPLANATION BILLING REMITTANCE ,-.$ - REMIT t <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT, <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t 013 <br /> Received by Date Receipt No Permit No.. <br /> lssuanc Date Mailed Delivered F <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT!$ERVICES - FP <br /> 1601 E.HAZELTON AVE.,P.O.Box 20139 STOCKTON,CA 95291 <br />