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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheApplication. <br /> FOR OFFICErUSE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t <br /> Application is hereby made tolheSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in complian aquin County Ordinance No.�118�62 Ad, <br /> the rules and regulations of the San J aquin oval Health District. <br /> Exact Site Address '�/r �4 L �Ad, City/Town <br /> I <br /> I <br /> Owner's N if IQ A.,11040 Phone <br /> Address 77 10 go 6-e . City <br /> Contractor's Name0twoeAffeX pi License#Aklq� Business Phone{�__► -� i <br /> Contractor's Addressiergency Phone <br /> Is Certificate of Workman's Compensation Insuran a on File With SJLI-ID? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ [y1l I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 6— PUMP REPAIR❑ <br /> REPLACEMENT❑ f 1 I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines IC42 =f Pit Privy ^ <br /> Sewage Disposal FieldCesspool/Seepage Pit Other <br /> Property Line_ Private Domestic WelI Ao9—C Public Domestic Well_�C <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> l <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br />_ ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 0 CATHODIC PROTECTION <br /> 11 ROTARY Type of Grout <br /> ❑\DISPOSAL ❑ OTHER Other Information <br /> C1 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor V P I Cok +J <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WE L: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and th the work will be done in acco ante 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 <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 t0w6rkman's compensation laws of California." <br /> I will call for a Groutjpspection prior to grouting and a final InWeerseCSd,) <br /> Signed X 1i Title: Date: <br /> (Draw Plot Plan on <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,r <br /> Application Accepted By !_ t � L�-�-�� Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P ase II Final I spection <br /> Inspection By Date �'" Inspection By" <br /> It <br /> It ate <br /> gelf <br /> I <br /> t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0 PER SITE ❑,EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ' REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> # FEE CIS g <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. k suance ale I Mailed - Delivered ' <br /> i <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />