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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 4 <br /> — FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, 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 Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance wi`th�Sf�n Joa uin County Ordinance No. 1862 and the rules and regulations of the San Joa uin Loc 1,Pealth District. <br /> Exact Site Address `TY_ _���p�f u rfCity/Town _577 C /r�/..!>�2 <br /> Owner's Nam 1 Phone — l; <br /> Address City t <br /> Contractor's Name ll License# ®' Business Phone z — <br /> Contractor's Address D Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No Z:,� (�11 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V t <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 /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> k�-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing / - <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sealy <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Y SoZG�1__�iQGf j��f .0 <br /> © DISPOSAL ❑ OTHER Other Information ir <br /> TT77 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor T <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done 0�1 <br /> PUMP REPAIR: ❑ State Work Done L <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. ! I <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call Iota-Grout In pection rior to grouting and a final inspection. <br /> Signed X / ✓L Title: ft/lt/�//�11� Dale j { �i <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ie�, <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection i <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 /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> 00 <br /> FEE <br /> 4 <br /> LESS <br /> PRORATtON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6 15 <br /> Received by Date Receipt No. Permit No. Issu nce Daie I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,rA 95201 <br />