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FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendab <br /> ENVIRONMENTAL HEALTH PERMIT_ PUMP&WELL <br /> (C ,mr-LETE 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 /> E made in compliance with S r o in County Ordi nce , o. 1862 t r nd regulations of the San J a L al a Is <br /> Exact Site Address <br /> City/Town <br /> Owner's Na Phone <br /> Address 7 City_, ,r–zr4, c� <br /> Contractor's Na a 44 J C License 934/aZBusiness Phone__. f— –'3 L/(-a!y <br /> Contractor's Addressav 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❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9' PUMP I I <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 Weil Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> r❑ DMESTIC/PUBLIC 11 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 /> ❑ GEOPHYSICAL Surface Seal Installed By: rl <br /> PUMP INSTALLATION: Contractor l� <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure . <br /> I hereby certify that 1 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 ceifles the following:"I certify that in the performance of the work forwhich this <br /> permit ' I sued, I shall employ per ns bject 'workman's compensation laws of California." <br /> I wil at for a Grou Ins ection p or ro ig and a final irspect f/ <br /> Signed X Title: Date: Q <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Additional Comments: Date <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE -❑ EACH ❑ January 1 &Received By January 31 ❑ Ju1y 1 &Received By July-31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION' DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALT <br /> OTHER . <br /> 1 <br /> OTHER <br /> Received by Date Receipl No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />