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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP &WELL r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> '[COMPLETE IN TRIPLICATE) ( WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is M <br /> made in compliance with San Joaquin County Ordinance-1,o.1862 and the r s and regulations of the San JoalWin LOCBYIjleal h District a r <br /> Exact Site Address 7 O ta12._ City/Town . <br /> Owner's Name Phone <br /> L City I F <br /> Address u e 2 ., <br /> Contractor's Name S License/2�'� Business Phone �' 9 Q ) <br /> Contractors Address C1f Emergency Phone <br /> !r <br /> Is Certificate of Workman's Compensation I�nJs�urance�on File With SJLHD? Yes No <br /> _j , <br /> TYPE OF WORK (CHECK): NEW WELL UCEPEN 11RECONDITION❑ DESTRUCTIO�N9❑�� <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11 - OTHER 13PUMP INSTALLATION�- PUMP REPAIR❑ <br /> REPLACEMENT❑_ _ .t-"' _ -- ._- . . _ _ ... p <br /> DISTANCE TO NEAREST: Septic Tank _ Sew Lines Pit Privy 7Y <br /> a Sewage Disposal Field / © Cesspool/Se Pu Pit Other <br /> �— a <br /> Property Line 'r_�Private Domestic Well _. PuPit <br /> Domestic Well i <br /> INTEND_&USEi' TYPE OF WELL �� 9' 3 <br /> ❑ INDUSTRIAL *- ❑ CABLE TOOL Die.of Well Excavation o,, <br /> 9Pt_5MESTIC/PRIVATE ❑ DRILLED Ola.of Well Casing <br /> t ❑ DRIVEN Gauge of Casing r <br /> ❑ D_OMESTIC/P 1�BLIG� - <br /> ❑'IRRIGATION �� '� �'. �_�❑ GRAVEL PACK – Depth of Grout Seal 9op <br /> e <br /> -*M CATHODIC PROTECTION - B'I OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _ Other Information ' <br /> Surface Seal Instal <br /> ❑ GEOPM--YSIGAIT_ <br /> PUMP INSTALLATION: ; Contractor ' y <br /> 'Of PUMP H.P. <br /> i - <br /> Type'-Of - O <br /> PUMP REPIACEMEN7: ❑ State Work Dom'•• - 0\ <br /> PUMP REPAIR: s,+ ❑ State Work Done <br /> DESTRUCTION OF WELL:' - Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that I'have prepared this application and thatAhe+work Wi�be-done in accordance with San Joaquin County 1 <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_t0 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 1 <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." ; <br /> 1 will I for a Grout Inspection prior to grouting and a final Inspection. I <br /> �� �� Title: Dater r <br /> Signed X `�•^'a'fT_- ' <br /> Draw Plotverse Side) <br /> I <br /> (J /S ARTMENT USE ONLY <br /> PHASE I�� / C� � /yj[ / Date S <br /> Application Accepted By <br /> ,1 Additional Comments: <br /> �P I Gro spectlon r�-�d a III final I pectlon <br /> Inspection By <br /> Date Inspection f Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN T ❑PER SITE 0 EACH ❑ January 1 8 Received By January 31 ❑ July 1 a Recsi REAyT my 31 <br /> BASE EXPLANATION BILLING REMITTANCE' S AMOUNT DUE CHECKED <br /> DATE DATE REMITTW AMOUNT <br /> 00 <br /> CS C1, <br /> 5 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY •. <br /> OTHER <br /> I OTHER <br /> R n L 1 <br /> _ <br /> Mailed Delivered <br /> t Receve by _1 1® Receipt No. permK No. <br /> APPLICANT=R¢TUANN•a,'CONES To: ENwRONMENTAL HEALTH PEnMITnIERWICEg -1801 E-iU2ELTON AVE.,P.O.Box 2008 BTOCKTON.CA 95201 �' <br />