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-Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applic ' n. _ <br /> FOR OFFICE USE: APPLICATION <br /> 1 (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL � <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY <br /> Application is hereby 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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. 1 <br /> Exact Site Addresseq � e ;y�� City/Town ! <br /> U � <br /> Owner's Name Phone _-,36- OC4 <br /> Address — 19es 'ir City _ <br /> Contractor's Names-moi roc License 43 �C � Business Phone <br /> Contractor's Address S® Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEWIWELL❑ DEEPEN ❑ RECONDITION 1:1 DESTRUCTIO,N❑�� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATIONS PUMP REPAIR❑ <br /> REPLACEMENT 11V_ <br /> DISTANCE <br /> V_ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy h` <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IN TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> LIDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 1 ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information r <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �+- <br /> PUMP INSTALLATION: Contractor C> <br /> Type of Pump H-P. <br /> PUMP REPLACEMENT: ❑ State Work Done - <br /> PUMP REPAIR: ' ❑ State Work Done <br /> i <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 forwhich 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 c r a Grout Ins p ction prior to grouting and a final inspection. f <br /> Signed X Title: Date: a4 <br /> 4 (Draw Plot Plan on Reverse Side) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Ah Q T Date <br /> Additional Comments: h <br /> Phase B I Grout Inspection ase Ill Fl�p Inspection <br /> Inspection By Date Inspection By Date� i�/l <br /> Ir. or <br /> Fee IS Due: ❑ ANNUALLY SII❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE `I EXPLANATION AMOUNT DUE CHECKED + <br /> li DATE DATE REMITTED AMOUNT <br /> VIII ys <br /> FEE <br /> LESS II. <br /> PRORATION <br /> PLUS <br /> PENALTY I� <br /> OTHER <br /> OTHER II i <br /> Received by Date il� Receipt No. Permit No. Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES`''TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE,P.O.Bax 2009 STOCKTON,CA 95201 <br />