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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR 2ff ICE USE: APPLICATION <br /> �a (For Non-Transferable, Revog-abje, Suspendable) <br /> ` PUMP&WELL <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 with San Joaguuin County <br /> OrdinaneNo1862 nd t e rules and regul"ri of the San Joaquin L&c I Health Dis 1ct. <br /> A w +Exact Site Address 7' 1?mtPs " tP2 " 69 r <br /> l <br /> I—&.Owner's Name ..fi1. [ L Z Phone <br /> Address ZV11 77de • City— <br /> Contractor's Name 1K License# Business Phone " �t ✓ �7l <br /> Contractor's Address J6.e57 ; ,645y_ Emergency Phone _-7/5-41"? <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL W"O' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ � <br /> DISTANCE TO NEAREST: Septic Tank !tom Sewer Lines Pit Privy <br /> Sewage Disposal Field l **-/- Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> C1INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation A3 <br /> Ifs DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing rye ,1146 _— <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing l6raw", <br /> ❑ IRRIGATION �/G�AVEL PACT{ Depth of Grout Seal -0f <br /> ❑ CATHODIC PROTECTION 29I ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ± _� f, UA44,-� \ <br /> ❑ GEOPHYSICAL Surface Seal Installed By. d .dLEC <br /> \ f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done \[1 <br /> PUMP REPAIR: ❑ State Work Done ) <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 San Joaquin Local Health District. <br /> Home owner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi I call for a Grout I pection prior to grouting anda f'WI inspection. <br /> Signed X `"/)/' ` G Date: J� <br /> (Draw Plot Plan on Revef9e ide) <br /> F R DEP R MENT USE ONLY <br /> PHASE I <br /> Application Accepted By '�^ ofN Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> EASE EXPLANAT#ON DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS tl <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> --7)1A q <br /> Received by lbate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE_,P.O.Box 2009 STOCKTON,CA 95201 <br />