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Application Will Be Processed When Submitted Properly Completed.Be SureTo signTneAppltc01110n. <br /> FOR OFFICE use: APPLICATION <br /> (For Non-Transferable, Revocable"Suspendable) I PUMP&WELL <br /> ENVIRONMENTAL-HEALTH 1PERMIT i <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> ,: <br /> Application is hereby madeto 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 with San Joaquin County Ordinance No. 8622 and <br /> the rules and regulations,of the San Joaquin Local Health District- <br /> Exact Site Address ��llJ/flF l yzll3 �,- [ City/Town <br /> t <br /> Phone'? <br /> Owner's Name ; <br /> ' tr <br /> City <br /> Address <br /> Contractor's Name <br /> License#?�,� Business Ph ne Z <br /> tLYl(,% Emergency`Phone <br /> Contractor's Address . 8�Q <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 13 WELL ABANDONMENT 13 OTHER-❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑: ... <br /> I� Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank � Sewer Lines Y o <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line_ Private Domestic Well Public Domestic Well 1 w <br /> r <br /> ` INTENDED USE TYPE OF WELL i. <br /> ❑ INDUSTRIAL " w ❑ CABLE TOOL Dia. of Well Excavation <br /> 4 2KQ61VIESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 13C/ <br /> DOMESTIPUBLIC ❑ DRIVEN Gauge of Casing <br /> 11 IRRIGATION GRAVEL PACK Depth.of Grout 5e <br /> ❑ CATHODIC PROTECTION ;K ROTARY Type of Grou ZnW 17725 <br /> ❑ DISPOSAL N ❑ OTHER Other Infor n <br /> ❑ GEOPHYSICAL j Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. <br /> PUMP REPLACEMENT:: I ❑ State Work Done <br /> ' PUMP REPAIR: A- r s 13 state Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth / <br /> i 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." z <br /> Contractor's hiring or-sub-contracting signature certifies the following:"I certify that in the performance of the work for which this M <br /> permit is issued, I shall employ persons subject to workrrtan's compensation laws of California." <br /> I will cal for Grout;lnspection prior to grouting and a final inspection. <br /> ,. r Title: �` Date: <br /> Signed X <br /> '4 (Draw Plot Plan on Reverse Side) # <br /> FOR DEP MENT I ONLY + <br /> PHASE I Date <br /> Appfication Accepted <br /> Additional Comments: <br /> las i ut Inspection Phase III Final Inspection <br /> Inspection By r <br /> =Dat��/ D Inspection By ` Date - <br /> ` Fee Is Due: ❑ ANNUALLY 114❑.PER UNIT ❑ PER SITE' ' ❑ EACH " ❑ January 1 &Received By January 31 ❑ July 1 R Received By July 31 <br /> _ REMIT <br /> IN BILLING __ REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE, 'REMITTED AMOUNT <br /> FEE i E <br /> LESS I E y <br /> PRORATION <br /> PLUS 4 <br /> PENALTY <br /> OTHER <br /> .-' OTHER <br /> Received by <br /> ...'Dale Receipt No - Permit NUL Issu ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL CO STOCKTON,CA 95201 <br /> PIES TO: ENVIRONMENTAL HEALTH PERMITISERYICE5' .� 1501 E.HAZELTON.AVE.,P.O.Sam 2009 <br />