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-- _u — <br /> Applications Will Be Processed When Submitted Properly omp e e e <br /> APPLICATION <br /> FOR OFFICE use: <br /> t;: , <br /> (For Non-Transierable, Revocable, Suspendable) -PUMP&WELL <br /> .. <br /> ENVIRONMENTAL HEALTH PERMIT /ry <br /> ' L U <br /> WATER QUALITY / <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application Is <br /> made in compliance ith San Joaquin ounty Ordinance. 1 62 and the ru�.a regulations of the San J in L cal Health, District. <br />'k �( � City/Town <br /> Exact Site Address <br /> 0 Phone ¢9v- 0 p `C/ <br /> &v <br /> k Owner's Name p <br /> i City_, - <br /> Address ?-f� �9 <br /> Contractor's Name '" License#- Business Phone <br /> Emergency Phone �� <br /> Contractor's Address 1 4— No _-ZIs Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL_Ltd' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> k DISTANCE TO NEAREST: Septic Tank Sewer Lines � Pit Privy _ <br /> Sewage Disposal Field 4Cesspool/Seepage Pit 0& 4mR Other.. <br /> Property Line 775! Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> _ ❑ INDUSTRIAL_ ❑ CABLE TOOL Dia. of Well Excavation <br /> ' 5XpOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing / <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing � <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> j ❑ CATHODIC PROTECTION ROTARY Type of Grout' `O/V <br /> C] pI CATHODIC <br /> 11 OTHER Other Information <br /> Surface Se installed y: � �� !M e- <br /> ❑ GEOPHYSICAL ) <br /> PUMP INSTALLATION: Contractor <br /> r <br /> Type of Pump H.P. <br /> l PUMP REPLACEMENT: State Work Done <br /> f PUMP REPAIR: ❑ State Work Done <br /> t DESTRUCTION OF WELL: <br /> 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 /> F 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 for which this <br /> f permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I 'II call for a Grout I i rl r to grouting and a final inspection. <br /> 1 CO + Date: <br /> I Signe Title: <br /> (Draw Plot Plan on Reverse Side) <br /> 1 @ FOR DEPARTMENT USE ONLY 2 <br /> i{ <br /> pHASEI Date <br /> Application Accepted By <br /> Additional Comments: <br /> / Phase III Final Inspection <br /> Phase11 Gra1 Inspection <br /> Inspection By Date <br /> y�-� ( Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMIT <br /> d By uIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> [ PLUS <br /> f PENALTY <br /> OTHER <br /> I OTHER <br /> Received by <br /> Date Receipt No. = Permit No. Issuance Date- Mailed Delivered <br /> t <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HAZELTON AYE.,P.O.Box 2009 STOCKTON;CA 95201 <br />