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f 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) <br /> v PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application ispereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> i made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health.Di�tr�� <br /> Exact Site Address /6aZ _ /Town �'IeZ .� 2. <br /> f 01 #- - <br /> Owner's Name C Phone �9a�� <br /> Address City <br /> Contractor's Name License#o24?Q,?1.3 Business Phone 97 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ElRECONDITION 11DESTRUCTION❑ _ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ [� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1401/ Sewer Lines Pit Privy <br /> i <br /> Sewage Disposal Field /f1Q 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 Dia. of Well Casing 42 f V6 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing A� <br /> ❑ IRRIGATION for GRAVEL PACK Depth of Grout Seal L50 <br /> ❑ CATHODIC PROTECTION fir.ROTARY Type of Grout A <br /> IIC4� <br /> ElDISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 K7 <br /> Describe Material and Procedure 7' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County (A <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 <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," —�}ARE <br /> 0 <br /> 7 <br /> 1 will all for a Grout Inspectio prior to grouting and a final inspection. J"1'�`C Iq <br /> Signed X Title: Date: 1�" <br /> (Draw of Plan on Revers Side) I <br /> FOR D PARTMENT USE ONLY <br /> PHASEI <br /> a <br /> Application Accepted y Date <br /> Additional Commen <br /> i Ph de, Grout Inspection[/ Phase III Final Inspection <br /> Inspection By Date T r��� Inspection By ®'ll Date <br /> ' Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED AMOUNT <br /> FEE <br /> LES5 ^; <br /> PRORATION <br /> PLUS ;F <br /> PENALTY <br /> OTHER <br /> ( OTHER t <br /> - Received by - Dati Receipt No. Permit No. - -Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br />