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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> kr_ " (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address . N City/Town /LQ/'/ <br /> Owner's Name Phone " <br /> Address City <br /> Contractor's Name [ /113 W644 �i�1L�//1/t, License#3970g!. Business Phone <br /> T 7— <br /> Contractor's Address V�44;%x -1� C��I �S; Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ Y <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank �4– Sewer Lines 1,gA2 Pit Privy r <br /> Sewage Disposal Field P Cesspool/Seepage Pit Other <br /> Property Line 40 Private Domestic Well Public Domestic Well - — <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL y$ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing � lL- <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �1 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By; <br /> PUMP INSTALLATION: Contractor . <br /> 7 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION-OF WELL: Well Diameter Approx epth <br /> Describe Material and Proc <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 will all for a:Gro t lns ecii or to grouting and a final inspection. / <br /> I Signed X Title: dh6A4eut� Date: Z� ! <br /> l (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By� Date_.. 1� <br /> Additional Comments: <br /> Phase II Grout Inspection Pha e III Final Inspection <br /> Inspection By Date Inspection By f r' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Fleceived By Jury 31I ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> i <br /> LESS <br /> PRORATION . <br /> PLUS d <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> � <br /> Received by Date Receipt No. Permit No. I uance Vale I Mailed Delivered- <br /> F' .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />