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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (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 permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County O_ rdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 3 - �- - City/Town <br /> Owner's'Name1=.A - r� uti Phone 6- <br /> Address � -1.�r�c e1�- �e-L� _ City.__ — <br /> Contractor's Name �t-Cs���-y-�Y 'P License Business Phone�r`�'`'�J :` `� f <br /> Contractor's Address C p <_ lc� 6d-� Emergency Phone _- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L-� No <br /> TYPE OF WORK (CHECK): NEW WELL❑- DEEPEN ❑ RECONDITION 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 /> ❑� 111 STRIAL ❑ CABLE TOOL_ Dia. of Well Excavation <br /> II-UViVIESTIC/PRIVATE I❑ 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 {f <br /> ❑ GEOPHYSICALSurface Seat Installed By: <br /> PUMP INSTALLATION: Contractor _C•n�j <br /> a Type of Pump H.P. <br /> PUMP REPLACEMENT: 10.State Work Done -eZ <br /> PUMP REPAIR: ❑ State Work Doney <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 Califorriia." <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 will call for,a Grout Inspection prior to grouting and a final inspection. <br /> t <br /> Signed X Title: �1 _ Dater T- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By - - Date 7 <br /> Additional Comments: <br /> Phase II Grout Inspection P s Final inspection <br /> Inspection 8y l 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 /> - - <br /> BILLING REMITTANCE $ REMIT <br /> BASE- .EXPLANATION - DATE DATE REMITTED AMOUNT DUE CHECKED <br /> }}� AMOUNT <br /> FEE <br /> LESS <br /> 4 } PRORATION <br /> PLUS - - - - - - <br /> PENALTY <br /> OTHER <br /> OTHER A , <br /> _ 4 —tabes i s_7r <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.Bot 2009 STOCKTON,CA 95201 <br />