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I - + plications Will Be Proceshen Submitted Properly Completed. Be Sure To Sign The Application, <br /> OFFICE USE: r ,- APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> NVIRONMENTAL HEALTH PERMIT � _ 2 3 c2-Zs'TH WATER QUALITY <br />/OR <br /> MI ETE IN TRIPLI ( CTR <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the wo rk herein described.'This application is - <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules ano regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> City/T"n <br /> Owner's Name " •`'' Phone rSJs <br /> Address AO City I <br /> Contractor's Name *'License#"':?-!?12 .3 Business Phone. Y —Contractor's Address Address d . 'Emergency Phone r r' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes)� No <br /> TYPE OF WORK (CHECK),-- -NEW WELL DEEPEN-11"" RECONDITION❑ - DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ ��T) <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy QJ <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ll <br /> Property tine Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 13 4 <br /> ❑ INDUSTRIAL 4 ❑ CABLE TOOL Dia. of Well Excavation- <br /> DOMESTIC/PRIVATE ❑ DRILLED T j' Dia, of Well Casing r�� <br /> ❑ DOMESTIC/PUBLIC ❑r DRIVEN Gauge of Casing <br /> ❑ IRRIGATION . 1w GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> C1DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ..Surface Seal Installed Sy: 7 <br /> PUMP INSTALLATION: Contractor <br /> r_ <br /> Type of Pump H.P. h <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 prepered 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 Sari Joaquin uin Local Health District. <br /> - <br /> _ . .� <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance otthe 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 for which this <br /> permit is issued, l shall employ persons subject to workman's compensation laws of California." <br /> y <br /> I wip call for a Grout Inection.prior to grou ng a final Inspectio . <br /> Signed X r i1le: Date: l �� •� _. <br /> (Draw PI t Plan on Reverse Side) <br /> ►r <br /> FO5,DEPARTME,1T USE ONLY <br /> PHASE I '� � <br /> t <br /> I <br /> Application Accepted By DatA— <br /> Additional Comments: <br /> has 1 but Inspection <br /> Inspection By Date y _ Inspection By /,)/,, _ Date <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 /> -BASE EXPLANATION- BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS J <br /> PENALTY v <br /> OTHER - <br /> OTHER - - - - <br /> Received by bate Receipt No. Permit No. Issuance Date Mailed- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />