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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. F <br />` EFORFFlce USE: APPLICATION <br /> (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 with San Joa uin County di`ante No.1862 and the rules and regulations of the Sa oaquin L cal Health District. <br /> Exact Site Address '44 4o� � f g <br /> AQT c� r City/Town ttC,f cf1.. <br /> Owners Na e ' o -�' '2 i" I� �Q Phone [ ._ t.� <br /> Address e L 01,1 <br /> City o �' <br /> Contractor's Name o cL _� ,� ) License } <br /> Q Business Phone �L ' t 7 I <br /> Contractor's Address G tom. �tf� .-tf Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ No <br /> DESTRUCTION❑ } <br /> WELL CHLORINATION. WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 11 i <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> p 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> &DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Dia. Well Casing J <br /> C1IRRIGATION Gaugea of Casing } <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information F <br /> ❑ GEOPHYSICALIf <br /> Surface Seal Installed 8y: Ltl <br /> PUMP INSTALLATION: Contractor cst> <br /> Type of Pump a,, . _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ <br /> PUMP REPAIR: State Work Done v aV <br /> DESTRUCTION OF WELL: Well Diameter, �a <br /> I Approximate epth r <br /> Describe Material and Procedure ( _ / <br /> r <br /> I hereby certify that I have prepared Mis application and that the work will be done in accordance with San Joaquin County N <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 /> sued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Co tractor's hiring or - ontracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> -pe t is issue ,shall em oy persons subject to workman's compensation laws of California." <br /> i cal! Insp tion prior 1 gr ling and a final inspection. <br /> e <br /> Signed X L Title: `? <br /> Date: l- � :) <br /> (Draw Plot Plan on Reverse Side) <br /> t <br /> PHASE FOR DEPARTMENT USE ONLY <br /> I <br /> Application Accepted By Date <br /> Additional Comments: ,;. <br /> Phase 11 Grout Inspection �y ha 1 I Inspection ! t <br /> Inspection By pate Inspection Bye/l/� <br /> jI Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Janu <br /> Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXP IANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE " �( �(f AMOUNT <br /> LESS Jr <br /> PRORATION <br /> PLUS r <br /> �p PENALTY <br /> OTHER <br /> i^t <br /> Received by Date Receipt No. Permit No. 'Issuance Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Delivered j <br /> 1607 E.HAZELTON AVE.,RO.'Box'2009 STOCKTON,CA 95201 <br />