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ApplicationsWillBeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> iFOR OFFICE USE: APPLICATION ` <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL; . <br /> L <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN.TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> I made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin oCal Health District, <br /> Exact Site Address � AS{JI (?. City/Town <br /> Owner's Name Phone �' 2 <br /> Address City <br /> Contractor's Name V e /1 5,1 License 741/ 0 Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance n File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK); NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®_PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> I DISTANCE TO NEAREST: Septic Tank c�Sewer Lines `7 S Pit Privy <br /> Sewage Disposal Fields Cesspool/Seepage Pit Other <br /> Property Lini 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 /> F ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I. ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor t)!� /I.'r'd V. <br /> Type of Pump H.p ' <br /> PUMP REPLACEMENT: State Work Done ' —� <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> t 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." I <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspe 'o prior Z:F:;:an <br /> ' final inspec ' <br /> Signed x Title: Date: ey J,� <br /> on everse Side) <br /> FOR DEPART ENT USE ONLY <br /> PHASE) <br /> Application Accepted By i"`^'- 'Date �f 7 - <br /> Additional Comments. <br /> Phase II Grout Inspection Phase Ii n nspection <br /> Inspection ByG!h. Date Inspection By Date <br /> I <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 r. <br /> FEE yS <br /> LESS <br /> 4 PRORATION " <br /> PLUS _ <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> ^gyp i ^� <br /> [ s <br /> Received by Date Receipt No. -xPermit No, Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2005 STOCKTON,CA 55201 <br />