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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 <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 wiith,San Joaq 7 Co y Ordinance No. 62 and the rules and regulations of the San aq in Local Heal h District. <br /> Exact Site Address 5 ` 6/4 E City/Town G. Cl A/' <br /> Owner's Name _ [L(f2�+� �'�(�J�( C l'�' Phone T0 C4 <br /> - <br /> Address City A G tv--d <br /> r <br /> Contractor's Nam ease to 57 Business Phone_ <br /> Contractor's Address Ow=ency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL COY DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ -t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank `fi Sgwer Lines Pit Privy <br /> Sewage Disposal Field � ! Cesspool/Seepage Pit Other <br /> Property Line:Je I Private Domestic Well Pubiic Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ®OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing S <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ®ROTARY Type of Grout �"�Q/l/t�,E <br /> ❑ DISPOSAL ❑ OTHER Other Information rt <br /> ❑ GEOPHYSICAL Surface Seal Installed By`:� _ <br /> M <br /> PUMP INSTALLATION Contractor <br /> Type of Pump H.P. p <br /> PUMP REPLACEMENT, 1❑State Work Done <br /> PUMP REPAIR: _ ❑ State Work Done a <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �+ <br /> Describe Material and Procedure `}} <br /> 1 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, V <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit a~ <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:.1 certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will call for a G u e 'on�riorgroutin�and final inspection.'`' t <br /> Signe Title: �sn F—aV-4)m-C� Date: A7z) <br /> (Draw Plot Plan on Reverse Side) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout lnspecqon / Ph se III Final Inspection <br /> Inspection By 7�pOrl Date —/ "' A Inspection By Date 111 <br /> Fee Is Due: Cl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &•Received By January 31 © July 1 &Received By July 31 i <br /> REMIT <br /> BILLING REMITTANCE $ j <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED # <br /> AMOUNT <br /> �/ i <br /> FEE "TJ y �✓ a <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER F <br /> Received by Die Receipt No. Permit No, Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES lsot E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ^� <br />