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Applications Will Be Processed When Submitted ProperlyCompiezea.6e nure 1uaiy+• ++��•+rr• - - � C O <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT "`+ 7 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtiora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance N . 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> - <br /> Exact Site Address 1�3 ;2-9_ City/Town <br /> Phone ~� Z <br /> Owner's Name <br /> City <br /> Address <br /> License#� Business Phon <br /> Contractor's Namee, <br /> Contractor's Address t `E`—' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONN O/ MP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION i--- <br /> U <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 /> ❑ IN TRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> 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 /> 11 GEOPHYSICAL Surface Seal Installed By: J <br /> c;:;. qJ <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H P. �Z14�r S <br /> PUMP REPLACEMENT: ❑ State Work Do <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." C <br /> I will caAfor a Grout Inspection prior to grouting and a final inspection. <br /> Signed <br /> AJ Title: Date: <br /> (Draw Plerse Side <br /> ot Pian on Re ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 Dated -2 <br /> Application Accepted By <br /> Additional Comments: <br /> Phase it Grout Inspection Phase Final Inspection <br /> Inspection By <br /> Date <br /> Inspection By Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January7l ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 �Z <br /> Received by <br /> Date Receipt No Permit No. is ante ate Mailed Delivered <br /> 1601 E.HA2ELTON AVE.,P.O.9o>t 2409 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />