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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-Translerable, Revocable;<Suspendable) ' <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance wl San J/o�aqui County Ordinance No. 1862 a the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address / '7 t� 5 City/Town <br /> Owner's Name Wy Adnlyrl Phone. �� C't <br /> Address City <br /> Contractor's Name OLoi AA-II(Am, License# 7.C,r ,l Business Phone 'Z / 1 <br /> Contractor's Address c<0/„� �c4,_.ler ��" Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No C) <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 12RECONDITION❑ DESTRUCTION❑ d <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ V <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 4- Sewer Lines &56 f Pit Privy <br /> Sewage Disposal Field f Cesspool/Seepage Pit Other <br /> Property Line© 4 Private Domestic Well Sd(� Public Domestic well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE © / I/ 10DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing !D . /Ir/a 19// _ <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 /> PUMP REPAIR: ❑ State Work Done r <br /> a <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure d <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. i <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 for which this { <br /> permit is issued, I shall employ perso subject to workman's compensation laws of California." <br /> I will cal for a Gr t In Clio ri r to routing and a final inspection, <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date d <br /> Additional Comments: <br /> Phase II Grout Inspection Ptill Final Inspection <br /> Inspection BytN I.. Date 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> :1 <br /> PENALTY ,t <br /> OTHER <br /> -U <br /> OTHER <br /> 17 <br /> Received by Date Receipt No. Permit No lissuance i Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E..HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />