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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) , <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE-IN TRIPLICATE) �715iV� /Dfi� �� WATER QUALITY <br /> Application is herety�made to the San Joaquin Local Health District fora permit to construct and/or install the Work herein described.This application is <br /> made in compliance-with San JoaquirLCounty Ordinance No. 1862 and the rules and re ul i ns of the aq Joa uin Local Health Dis ict. <br /> i <br /> 9 q <br /> Exact Site Address � <br /> Owner's Name C'0Se—) Phone 36 —d,�ZZ- <br /> Address 679-- City <br /> Contractor's Name License#_c:�.Va M-3 Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensations,urance on File With SJLHD? Yes �� No { <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ W <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 160 Sewer Lines Pit Privy <br /> Sewage Disposal Field /OU �^ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �, -C <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC El DRIVEN Gauge of Casing ZdD!I>�J. t <br /> ❑ IRRIGATION XGRAVEL PACK Depth of Grout Seal J`�4 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout � 7f2st <br /> ❑ DISPOSAL ❑ OTHER Other Information —6 <br /> i <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. U <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 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 for which this ' <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." I, <br /> I will call for a Grout I pecI-on prior to grouting and a final inspection.- <br /> Signed X Title: /' Date: i <br /> {Dra Plot Plan on Reverse Side) <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I p p <br /> Application Accepted By Date a U 6 <br /> Additional Comments: <br /> Ph s / rout Inspection 2 Phase III Final Inspection <br /> Inspection By e!� Date �� / � Inspection By A Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED i <br /> DATE DATE REMITTED AMOUNT - <br /> FEE c L <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No -IS ance D to Mailed Delivered } <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />