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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FQR OFFJ4 USE: APPLICATION ,�.. <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> » t v `ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby to the San Joaquin Local Health District for a permit toconstructand/orinstallthe w described.This application is <br /> made in corn wit an Joaquin ounty Ordinance N . 186 and the rules and regulations of the Sa Joaqui oval Health riot. <br /> Exact Site Addrss D tt! C City/Town <br /> 7 UlO C v�-+�S �L r, 16�a A/-, � <br /> Owner's Name Phone <br /> Address / (�..� City �'e S <br /> Contractor's Nam ense#, 60 YIV Business Phone <br /> Contractor's Address , Emergency Phon ' t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL M DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> ,DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Pri y <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 /> [1 IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea] <br /> ❑ CATHODIC PROTECTION0-1175TARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> r <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 /> 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 California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work fol which this <br /> permit is issued, I shall em pe ons subject to workman's compensation laws of California." <br /> ill call for a Grou In e o rip to grouting and a final Inspection..(3Lt-'t��� ��,,,.� <br /> Si Title: OAA 5;zi n9 Date: <br /> {Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHA Q,Ck_ Date �7— 20-2 <br /> l <br /> Application Accepted By — <br /> Additional Comments: <br /> Phase li Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PEF(UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January.31 ❑ July 1 &Received By Juty 31 <br /> BILLING REMITTANCE $ REMIT <br /> r BASE EXPLANATION DATE DATE REMITTED s AMOUNT DUE CHECKED <br /> AMOUNT <br /> o aYD <br /> FEE <br /> LESS <br /> PRORATION <br /> Pius <br /> PENALTY <br /> OTHER -e /L Lou 1, G�4Y VA <br /> OTHER <br /> _ -7 � i <br /> Received by Date Receipt No. Permit No Issuan Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E_HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />