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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICgUSE: APPLICATION <br /> tv (For Non-Transferable,-Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto 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 Sal gquiI L I Health District. <br /> Exact Site Address �� -� S City/Town <br /> ¢- y(dl DC-'✓ � �• <br /> Owner's Name A` ,A ~ ✓ x114-lam` Phone C" 76-5 !! <br /> Address lv S, S41 City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone �- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION 0 - DESTRUCTION_ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 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 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑-GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ' ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION:. Contractor 1 <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 'y Approximate Depth vl <br /> Describe Material and Procedure -. za.r P • ' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> j 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 theperformance 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 /> j ContractoLarout <br /> Ing or sub-contracting signature certifies the following:"I certify that-in the performance of the work for which this <br /> permit is shall employ persons sub- t to workman's compensation laws of California." <br /> will,c III In ii rior t rg uting and a final inspection. <br /> A / 7�l <br /> Signe X _ Date: <br /> I Draw PI Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By - Q Date <br /> r - - <br /> Additional Comments: <br /> Phase 11 Grout Inspection, _ tease 111 anal Inspection! <br /> Inspection By Date - "_-� Inspection By Date L' ��� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &r Received By January 31 ❑ July 1 &Received By July 31 <br /> B _ REMIT <br /> BILLING REMITTANCE' $ <br /> RASE 'EXPLANATION k DATE DATE REMITTED AMOUNT DUE -CHECKED <br /> AMOUNT <br /> FEE �� Y,3 ' <br /> LESS <br /> PRORATION r _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> LIZ 1 <br /> Received by Dat Receipt Nn. Permit No. Issuance Date. Mailed Delivered » <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />