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Applications Will Be Processed When Submitted Properly Completed. Besure iosign IneApPIu;auaIN. <br /> FFOR�2:USE: A P P L I `�}T��N <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District far a permit to construct and/or install the work herein described.This application is <br /> made in compliance with an Joa uin unty Ordinance No. 1862 and the rules and regulations of the Sal] Ja uin t oa4 Health District" <br /> Exact Site Address d City/Town <br /> Phone <br /> Owner's Name r <br /> Address City Gil <br /> Contractor's Name 7 7 9 <br /> icense#� ��/ Business Phone !' <br /> _ <br /> Contractor's Address Emergency Phone - <br /> i Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _". No (b/I <br /> r` TYPE OF WORK (CHECK): NEW WELL I_ DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ �1 <br /> WELL CHLORINATION 13WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> 'REPLACEMENT❑ N <br /> i' Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Sewage Disposal Field A570 Cesspool/Seepage Pit Other <br /> Property Line�eQ _ Private Domestic Well Public Domestic Well <br /> :s INTENDED USE TYPE OF WELL <br /> r ❑ INDUSTRIAL X—CABLE TOOL Dia. of Well Excavation � 1f <br /> r ❑ DRILLED Dia. of Well Casing <br /> F: ;�-DOMESTIC/PRIVATE + � <br /> 11p�DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> + ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout .� — __ ' <br /> ❑ DISPOSAL <br /> ❑ OTHER Other In e <br /> 13 GEOPHYSICAL Surface Seal installed By: <br /> PUMP.INSTALLATION: Contractor � <br /> H.P. Amm �. <br /> Type of Pump <br /> PUMP REPLACEMENT: '❑ State Work Done <br /> PUMP REPAIR: *❑ State Work Done {F <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> f" <br /> a • <br /> i <br /> I hereby certify that 1 have prepared this application and that the work will be done in adance with San Joaquin County <br /> ' ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.' <br /> ' I <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 farwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of Ca�ornia."„ <br /> I will c ll for a Grout I spection prior to grouting and a final Inspection. I W <br /> To <br /> Signed X �a Title: `�I Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> „9. x <br /> PHASE I T Date 1_0 <br /> }- Application Accepted By <br /> Additional Comments: <br /> Phos Il Grout Inspection P se NI Final Inspection <br /> s f <br /> Inspection B Date `) Inspection Byf Date <br /> R UNIT ❑ PER SITE ❑ EACH ❑`January 1 &Received y January 3 ❑ Juky 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER REMIT <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I s; <br /> FEE <br /> I LESS <br /> I <br /> PRORATION ''# <br /> _ -PLUS ..« .,,...... <br /> PENALTY <br /> t - F OTHER <br /> If <br /> iE <br /> ' CTHER ...t <br /> -� Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O:Box 2099 STOCKTON,CA 95201 <br /> b c� <br />