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T Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. j <br /> FOR OFFICE USE: _ APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto constructand/or install the work herein described.This application is <br /> k 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 � � S� eW0P-,K V, City/Town 1 <br /> i Owner's Name�S A►J1� L 1a W)RT l Phone <br /> AddressL W City <br /> Contractor's Name G icense# 'I'iCF6V3 Business Phone <br /> Contractor's Address c\ Irgency 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 /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank A9[) _.t_� Sewer Lines Pit Privy ti <br /> Sewage Disposal Field ;4JQ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> © INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation X1.3 �r nL'� <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing / <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> s r <br /> ❑ IRRIGATION dal 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. �U <br /> PUMP REPLACEMENT: ❑ State Work Done ^' <br /> I PUMP REPAIR: ❑ State Work Done P <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> Homeowner 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 persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X �??J. Title: -�/t Date: <br /> (Dr Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> 1 PHASE 1 L <br /> 1 Application Accepted By Date <br /> F Additional Comments: <br /> t Phase !!^rout InspectionP ase III Final Inspection <br /> ' Inspection By Date,f Inspection By Date <br /> f <br /> i <br /> Fee Is Due: ❑ ANN ALLY ❑ P NIT ❑ 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 /> f FEE w3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ' OTHER <br /> OTHER <br /> 1 Received by D to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> t' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2000 STOCKTON,CA 95201 _ <br />