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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) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 188§2 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address .7Tl A/Tzie11 F !! .,.. City/Town '%� GCL _ <br /> Owner's Name DeAl CCOC—r, Phone <br /> Address l� City C r7 <br /> Contractor's Name rAJ gJA7z FD (ZIMA2 4iLicense# `, ,12 Business Ph e 71r'J/ t <br /> Contractor's Address V42 Emergency Phone <br /> Is Certificate of Workman's Compensation lnsur ce On File With SJLHO? Yes 7>� No (}� <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION C3 DESTRUCTION❑ o� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank &fo Sewer Lines Pit Privy + <br /> Sewage Disposal Field AgJ2 z::�% 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 42- <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ?41C Z6 19 <br /> ❑ IRRIGATION EZ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION OTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 /> 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. <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 torwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca to a Grout Inspection prior to grouting and a final inspection. rR x <br /> Signed )( Title: Date: V <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By '` Dater /y <br /> Additional Comments: <br /> PhaW II Gr ut Inspection PhaseII inal Inspection <br /> Inspection By Date/;F Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received 6y July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE C <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> LS <br /> Received by Date Receipt No, Permit No. lssuadc6 Dat Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />