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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) t PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT f 9 3 <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 Joaquin County Ordinance No. 1$62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address1_ CJ.�/+ <br /> _"" City/Town <br /> Owner's Name DL19,A' c�c,Ra` — Phone <br /> Address City 3 <br /> Contractor's Name 4 License#!=S? �I Business Phone <br /> Contractor's Address 4Emergency Phone - . <br /> Is Certificate of Workman's Compensation Insurance on File WA SJLHD? Yes No ,_ <br /> TYPE OF WORK (CHECK): NEW WELL❑1 DEEPEN ❑ RECONDITION❑" DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP-INSTALLATION_Z,-�PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other j <br /> Property Line ) Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IN STRIAL ❑ CABLE TOOL { Dia. of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION 11 'ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I �, Su#ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor .I O,t ;. �u <br /> Type of PumH.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 /> � 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance With San Joaquin County x4 <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 d <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 /> t <br /> I will ca a Grout Inspection prior to grouting and a final inspection. <br /> Sign Title: 15�1 `s`f <br /> (Draw Plot Plan on Reverse Side) <br /> F DEPA MENT USE ONLY <br /> PHASE l +`fes/�� C <br /> Application Accepted By - Date <br /> Additional Comments: <br /> Phase I! Grout Inspection Ph s I Final-Inspection� � <br /> Inspection By f Date _ -- - - - -- Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT '❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Q July 1 8 Received By July 31 <br /> REMIT <br /> BASE - EXPLANATION BILLING ., REMITTANCE _ $ - AMOUNT DUE CHECKED <br /> DATE DATE _ REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY k ' <br /> OTHER J <br /> OTHER f <br /> Received by - Date .. Receipt No. _ Permit No. - 1 suance DaW& Mailed Delivered / .. <br /> A``.APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11011 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />