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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) I <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT lu <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 ism <br /> made in compliance with San Joaquin County Ordinance No. 1862 and th /rules and regulations of the San J quin Local Health District. <br /> Exact Site Address c� � JM. � 1 City/Town Qt �'1'fUi7 <br /> � J <br /> Owner's Name '/1 e r . Phone ` <br /> Address r 1I C, city <br /> Contractor's Name� S '� License# Business Phone <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 ❑ RECONDITION❑ DESTRUCTION <br /> WELLFCHLORINATION ❑ WELL ABANDONMENT C1 OTHER El PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other— <br /> Property <br /> ther Property Line Private Domestic Well Public Domestic Well <br /> INTEN_D_ED USE TYPE.OF WELL <br /> 11INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVENGauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK "� `� Depth of Grout Seal <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 /> : —��- - <br /> PUMP REPAIR:- 11 State Work Done <br /> DESTRUCTION OF WELL: We Diameter Approximate Depth <br /> r Describe Material and Procedure � d-L ,s6�l 0 <br /> I; I hereby certify that I,"%a e=prepa ed 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 orI•censed agent's signature eertifles.the following:"I certify that in the performance of the work for which this permit <br /> is issued, I s ! of employ any person in-such manner as to become subject to workman's compensation laws of California." <br /> Contract s hir ng or sub-contracting sigpature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit i issu , I shall persons surNect to workman's compensation laws of California." <br /> -, I will II for Grout Ins on prior to grouting and a nal inspection. , <br /> Signed X 7 Title: Date: /.Z LC,— f 9 <br /> ( raw Plot Plan on Reverse Side) <br /> FOR DEPAR11MENT USE ONLY <br /> PHASE lY �. <br /> Application-Accepted-B - Date <br /> Additional Comments: <br /> y Phase 11 Grout Inspection Phase Inspection 'F <br /> Inspection By Date Inspection By Dateit flil� <br /> Fee Is Due: ❑ ANNUALLY ElPER UNIT E] PER SITE I-] EACH ElJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> i BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> e.13 1 c� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 o� _7� i t_ 4 719 —\:5 � <br /> Received by Date , Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES F -1601 E.HAZELTON AVE:,P.O.Box 2009 STOCKTON,CA 95201 <br />