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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) i <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) ,_3 z.YATER QUALITY ®v3^zd3o„ 2- <br /> Application is hereby madetothe San Joaquin Local Health District for a,permit to construct and/or install the work herein described.Thisap licationis <br /> made in compliance ith San Joaquin County Ordinance No. 1$62 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address �1 6C Qjl-01'1066- , "rG'A6106"T0 9D - ity/Town <br /> Owner's Name Phone <br /> Address City t1<41"gea �� O <br /> Contractor's Name ll/ License#' 74rz Business Phone � <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 2C No 4— <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ 6<:ee2 r Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit --- Other��� . <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE USE TYPE OF WELL <br /> ❑ <br /> INDUSTRIAL ` 3� { <br /> CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED - "Did. of Well Casing <br /> *IRRIGATION 11 <br /> 11 DRIVEN Gauge of Casing <br /> �rI�IRRIGATION 11GRAVEL PACK Depth of Grout Seal <br /> �` CATHODIC PROTECTION ❑ ROTARY Type of Grout f°i I <br /> ❑ DISPOSAL ❑ . rM _ 3 <br /> OTHER -- Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor fF,4_,/ / ff:pz Ae,&&r,o*�! <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit l i <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, I shall employ persons subject to workman's compensation laws of California." 3 <br /> I will c I lfor a Grout Inspecti n prior to grouting and a final inspection. <br /> Signed X f Title: Date: <br /> (Draw Plot Plan on Reverse Side) — e <br /> - -. FOR DEPARTMENT USE ONLY <br /> PHASE_1 <br /> Application Accepted By Date's <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> .Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASEEXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ��� e� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Oate Receipt No. Permit No Issu rice Oate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />