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FOR OFFICE USE: APPLICATION <br /> �Ohtr �6 T� 'For Non-Transferable, Revocable, Suspendable` L� <br /> - ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (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_ounty rdina ce No. 1862 and the rules and regulations of the San Joa` 1 0 1 Health District. <br /> Exact Site Address 3!EQ�} �d t ai` City/Town v � <br /> Owner's Name r P,10 �! J� 74-0 <br /> Phone <br /> Address 4v 6• o City- <br /> Contractor's <br /> ity Contractor's Name License# ` -�lJ� Business Phone 6 76 <br /> Contractor's Address o, Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fi With SJLHD? Yes--X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1 <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 --C <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> J4 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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t_ a <br /> Type of Pump �'!<d_ ,- _�/e H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: P State Work Done t/ <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 /> I W11 call for a Grout Inspect' n In r t grou ' g and nal inspection. <br /> Signed X QR tle: �� K, Date: j <br /> (Draw Plot an on Reverse Side) f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <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 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS �G <br /> PRORATION G <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 11,lit <br /> Received by Date Receipt No. Perrriit No. G 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 />