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Applications Will Be Processed When Submitted Properly Completed. Be StareTo SignTheApplication <br /> FOR OFFICE USE: APPLICATION <br /> i <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 5 <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 an Joaquin Cou Ordinance o. 1862 and the,rules and regulations of the San Joaquin Local Health District" <br /> Exact'Site Address / City/Town <br /> Owner's Name -3 � T- 3.,37 <br /> Phone _ <br /> Address p � �� City_ec&—ee-`: <br /> Contractor's Name License#/ 7Business Phone <br /> Contractor's Address j d 6-2.% Emergency Phone .1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes✓ No <br /> TYPE OF WORK (CHECik): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> s WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 16-' PUMP REPAIR❑ Y <br /> REPLACEMENT❑ n;�n <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Well { <br /> INTENDED USE TYPE OF WELL - FEB 11 1981 ' <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation ' <br /> ❑ DOMESTIC/PRIVATE ❑ DRILL-ED Dia. of Well Casing J <br /> low LOA a <br /> � <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ciii-ir 1.1 <br /> 91-'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal EIV • r1L7 11 ' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ; <br /> ❑ DISPOSAL ❑ 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 <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 a <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 /> I I call f a Grout In ec" n prior to grou' g and a final in ction. <br /> Signed X .. Title: Date: <br /> (Draw <br /> an on Revet4e Side) <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I � '� " <br /> Application Accepted By r Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pha 11.1 Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January ❑ July 1 &Received By July 31 i <br /> BILLING REMITTANCE $ REMIT rr <br /> BRSE EXPLANAT40N AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> -AMOUNT <br /> r <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> F OTHER <br /> OTHER `- <br /> V �- $ � <br /> '`•ed by Date Receipt No Permit No. Is uance bate Mailed Dekivered <br /> NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.,Box 2009 STOCKTON,CA 95201 <br /> ..70 <br />