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Applications Will Be Procrs-ed=When Submitted Properly Completed. Be Sure To Sign The Application. ~ <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> e" PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT _ <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 S n Joaquin Cou/�n�ty�`Ordi ce N 862 a the rules and regulations of the San Joa . LocaVHealth District. <br /> Exact Site Address � (C rP � A// �g _�l�'� City/Town 1"�J AY fjljv <br /> Owner's Name //�G�( L_ �/dl� _ _ Phone <br /> Address City <br /> Contractor's Name P.1 icense Business Phone l <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation In ranee on File With SJLHD? Yes d� No <br /> TYPE OF WORK (CHECK): NEW WELL®'— DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9�' PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank �Sewer tines _5,— GAJ -i— Pit Privy"— e� <br /> Sewage Disposal Field Cesspool/Seepage Pit ��!C1 T" �Other <br /> Property Line 45�P 14Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL / J <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 91'6—OMESTIC/PRIVATE ❑BILLED Dia. of Well Casing SPC',4 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal e <br /> ❑ CATHODIC PROTECTION L-ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sprface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ` er H.P. r <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 <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 It foraout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Csl� 1 ���. Date: L� <br /> (Draw Plot Plan on Reve se Side) <br /> FOR PARTME T USE ONLY <br /> PHASE t <br /> Application Accepted Dat�-2 /�7 <br /> Additional Comments: <br /> s P e II Grout Inspection Phase_I�I Final Inspection <br /> Inspection By Date__j �`�� Inspection By r fl`hFf`n�'A/ �ate b <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 /> BILLING REMITTANCE 5 <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS r+ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 0�4 <br /> OTHER <br /> OTHER <br /> b A <br /> Received by Date Receipt No. Permit No Is§uanee Date Mailed Delivered <br /> ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,.CA95201 <br />