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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR rFICE USE, APPLICATION <br /> (For Non-Transferable, Revocable,Suspendabie) PUMP&WELL a <br /> -a ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) —WATER QUALITY <br /> Appl icat ion is hereby made to the San Joaquin LocaI Health District for a permit to construct and/or install the work herein described,This application is <br /> made in compliance with San Joaquin.County,0 dinance No, 1862 and the rules and regulations of the San Jbaquin Local Health District. 1 <br /> /_ <br /> A, i sh yl*' t4 �€r.mss. City/Town rti Jr <br /> Exact Site Address <br /> � � L.x-ri.<'..,,�ilt �-��:.�p�s��:...�,,..-'-�✓ Phone `..,��C�,�- r.i fr <br /> Owner's Name Cit 1 <br /> z r y <br /> Address r <br /> {r ice% fes- ,�. License# =F=` Business Phone <br /> Contractor's Name <br /> _ <br /> Contractor's Address / ' `'" Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ W-3 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _ Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well - Public Domestic Well <br /> I TENDED USE TYPE OF WELL i <br /> NDUST.RIAL. r... - ❑ CABLE-TOOL -•+. — Dia. of Well Excavation ; <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout + <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I] GEOPHYSICAL „,Surface Seal Installed By: <br /> PUMP INSTALLATION. Contractor ?! <br /> - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> [!"State Work Done ' ` '�v . .� <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 /> 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." t <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this #5 <br /> permit is issued, I shall employ persons subject to workman's compensation laws.of California." <br /> I will call for.a Grout_ Inspection prior to grguting and a final inspectlon. <br /> / ef/­, ? _,�> Date: • •� i �, <br /> Signed X y Rile: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASEI I <br /> �' - Date- _9_ <br /> Application Accepted By } <br /> Additional Comments: <br /> Phase I1 Grout Inspection Phase III Final inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January l &'Received By January 31 ❑ July 1 &ReceivedREMITuly 31 -- <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> ys s`— <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER , <br /> Permit No. Issuance ate Mailed Delivered <br /> Received y Date Receipt No. _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXELTON AVE.,P.O.Box 2009 STOCKTON.! <br />