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- f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pUMP&WELL <br /> *y .. .„� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to 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 wi1b S e�nd_Inaquin County O dinance No.�fi2 and the rules and regulations of the San Joaquin Local Health District. <br /> G4/�^,���'� � . � City/Town <br /> Exact Site Address .7-F� / x <br /> Phone 1 <br /> Owner's Name r <br /> Address 319 City i <br /> Contractor's Name icense# 6f�:L/ Business Phone_ <br /> �l_Z 7k7 <br /> .J" 1 <br /> ���- a= �� �1 Emergency Phone <br /> Contractor's Address <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 11 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 /> C1 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done C_ �"w <br /> PUMP REPAIR: ❑ State Work Done '{ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <br /> Describe Material and Procedure <br /> u <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." <br />[ Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br />". permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> C I will It for a Grout Inspection.pririor�to grouting and a final inspection. <br /> Signed X -�" - Title: _ Date: <br /> ti� o- <br />`" g (Dr Plot Plano Reverse Side),/ <br /> to 'VeF ra TAr�v�e& fip �QL e/�o c. <br /> k FO DEPARTMENT USE ONLY /!S--2 -F0- Gf/e-C'-F/• - ��'e <br /> f PHASE i Date �91490 <br /> Application Accepted By <br /> Additional Comments: <br /> 'Phase II Grout Inspection a III Fi In�s�ection <br /> Inspection By Date Inspection B Date���� <br /> r & <br /> r <br /> Fee IS Dile: ❑ ANNUALLY [3 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Heceived By Januar © 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 ry <br /> PENALTY <br /> OTHER .~ <br /> OTHER 7x( <br /> Received by Date Receipt No. Permit No.- ssu nce Date Mailed Deli d <br /> o APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O."Box 2009 STOCKTON,CA 9W1 <br />