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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplicationZ_V_ l/� <br /> FOR OFFICE USE: APPLICATI O ;I " <br /> (For Non-Transferable, R b E9p .t� e) <br /> PUMP&WELL � <br /> ENVIRONMENTAL �H PERMIT ggd <br /> 1 �4 c <br /> (COMPLETE IN TRIPLICATE) WATER Q �v G U <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the y Lherein described.This application is <br /> made in compliance with San Joaqu Coun rdina a yo. 1862 and the rules F�gu�atibq��, quin Local Health District. <br /> Exact Site Address 7 "(Qrry 14 R <br /> r C� <br /> Owner's NamePhone ! - "7f36 __ 1 <br /> Address41%__1 I Y city <br /> Contractor's Name License#/G.2� 7� Business Phone (o <br /> - � <br /> Contractor's Address '����f � :� _ Emergency Phone 5P6 _ <br /> � (, -- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ( r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR�� i <br /> REPLACEMENT❑ �. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy -as <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 I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Su ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor IS <br /> Type of Pump H.P. f " <br /> PUMP REPLACEMENT: ❑ State Work Done LA <br /> PUMP REPAIR: CE-State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby ce-rtify that I have prepared this application and that the work will be done in accordance with San Joaquin County �f <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r <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 becoiTle-sObject 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws Of California." <br /> I wiH for a Grout Inspe tion prior to grouting and a final inspection. <br /> Vr <br /> Signed X TitleDate: <br /> rOraw Plot Plan on Rever Side) — w - --- �— ; <br /> FOR DEP TMENT U ONLY <br /> PHASE 1 <br /> Application Accepted By Date 7 <br /> Additional Comments: <br /> Phase 11 Grout Inspection r P /II Final In ecti <br /> Inspection By Date_ Inspection By / a f/ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br />' FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. 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 />