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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION � f <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> + ENVIROjVMENTAL HEALTH PERMIT <br /> R . (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 Ordinance 1862 an the ules an re uta ons of the San Joa 'n Local H Ith District. <br /> Exact Site Address �%� � r � � � City/Town r--•r-�i�d <br /> Owner's Name , 111 0. Phone � <br /> Address c City <br /> Contractor's Name License IV`f3 ' Business Phone , <br /> Contractor's Address Address Emergency Phone �_�' lrl� z q <br /> Is Certificate of Workman's Compensation Insuran on File With SJLHD? Yeses' No <br /> JI TYPE OF WORK (CHECK): NEW WELL DEEPEN C1 RECONDITION I-] DESTRUCTION❑ <br /> 1! . WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 <br /> i REPLACEMENT❑ _ <br /> FDISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> y Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line G Private Domestic WEN Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑, IND STRIAL ❑ CABLE TOOL Dia. of Well Excavation !� <br /> OiMESTIC/PRIVATES ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ D�;VEN Gauge of Casing 1 __ <br /> r^ ❑ IRRIGATION 91'-GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: cam- <br /> f PUMP INSTALLATION: Cori tractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ii P <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will call,or a "ut Inspection prior to grouting an -p final inspection. <br /> L Signed X —� _� .. '' �'l Title: C�' Lw-_{� <br /> Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> Fr FOR DEPARTMENT USE ONLY <br /> PHA5E1 <br /> Application Accepted By z&f"F4 ".=7 Date �" <br /> __41P <br /> Additional Comments: <br /> fPharre I _Gr ut Inspection Fh5we� final Inspection <br /> Inspection 8y_ �' �� Date Inspection By `� ;We __S3 <br /> ` <br /> I Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ElJuty 1 &Received By July 31 , <br /> J REMIT <br /> RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUECHECKED <br /> {{'''' rr DATE DATE REMITTED AMOUNT <br /> FEE L. ' <br /> * LESS <br /> PRORATION <br /> r, PLUS i_5 <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER <br /> Li is <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TOS ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />