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r <br /> � Applications Will Be Processed When Submitted Properly Completed. t5e <br /> ffOFFICE use: APPLICATION <br /> t p �p� (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> -ENVIRONMENTAL HEALTH PERMIT <br /> t <br /> ­-WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) S.`sT ,J r4=✓1E - e work herein described.This application is <br /> Appircation is hereby made to the San Joaquin Local Health District fora permit toconstruct and/or install the <br /> Ate., <br /> made irtscompliance with San Joaquin Count Ordinance No. 18 2 and the rules and regulations of the San Joaquin Local Health District. <br /> k Exact Site ddress �✓ � )� F 8' 4� City/Town <br /> i IP Qve� sPhone <br /> P Owner's Name ^- <br /> ✓3.0city <br /> Address <br /> Contractor's Name ,. License# � Business Phone �J <br /> Emergency Phone <br /> Contractor's Address 1 <br /> Is Certificate of Workman's Compensation Insurance on File Wit JLHD? Yes No <br /> k TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11RECONDITION❑ DESTRUCTION❑ <br /> ( WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y Pit Privy <br /> Sewage Disposal Field rCesspoolYSeepage 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 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing o <br /> e <br /> F-1 DOMESTIC/PUBLIC ❑ DRIVEN Gauge,-of Casing <br /> y 0 IRRIGATION ❑ GRAVEL PACK ,Depth of Grout Sea! <br /> ❑ CATHODIC PROTECTION ❑ ROTARY '`,Type of Grout <br /> ❑ DISPOSAL 11 OTHER <br /> Other Information <br /> ❑ GEOPHYSICAL , Surface Seal tailed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.' S� <br /> t PUMP`REPLACEMENT: ❑ State Work Done <br /> PUMP,REPAIR: f JR State Work Done s <br /> aM <br /> € DESTRUCTION OF WELL: ,_ -Well Diameter. = Approximate Depth <br /> f 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 San4oaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhicfi 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 far which this <br /> permit is issued, I shall employ persons subject to workman's compensation law`s 6f California." <br /> 1 I will call fora Grout sp ilo pri o outing a a final inspection. <br /> Signed dh L-4- <br /> ®/ - Title: nate: <br /> (Draw PI Plan on Reverse Side) <br /> I N:. <br /> FOR DEPARTMENT USE ONLY �^7 <br /> PHASE I c D <br /> G <br /> Date�sn r n <br /> t Application Accepted By I <br /> Additional Comments: <br /> Phase II Grout inspection Pha/�Jse_"III Final inspection <br /> k. inspection By�, �-�c�-A-,--- + Date <br /> Inspection By -Date 7 31 r�'I <br /> i <br /> Fee Is Due: ❑ .ANNUALLY ❑ PER UNIT ❑ PER SITE EACH © January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASEEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> f FEE -eQ� <br /> LESS <br /> _PRORATION. <br /> PLUS <br /> PENALTY <br /> OTHER1 <br /> OTHER 7 <br /> Received by Date Receipt No. PermitNo_ lssuan a Date Mailed Delivered ;-•-1, <br /> 'APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 7601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON:CA 95201 . <br />