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_ ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. L <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> t Application is hereby madetotheSan Joaquin Local Health District forapermittoconstruct and/or install the work herein described.This application is " <br /> made in compliance with San Joaquin County Ordinance No. 1862 and he rules and regulations of the San Joaquin Local Health District. <br /> i Exact Site Address MS is <br /> ~ i City/Town <br /> Owner's Name f ij tr' Phone <br /> Address 4 City <br /> Contractor's Name •+ 1- C.�� License# �_3 Business Phone <br /> j# Contractor's AddA&. d Emergency Phone ` <br />! Is Certificate of Workman's Compensation Insurance on File-With SJLHD? Yes Lr No <br /> 9 TYPE OF WORK (CHECK): NEW WELL j:�EEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ 'WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> t DISTANCE TO NEAREST: Septic Tank _ 5p� Sewer Lines <br /> Pit Privy ) <br /> t Sewage Disposal Field Ce§spool/Seepage Pit Other <br /> Property Line; Private D'Tr6estic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ®"r?OMESTfC/PRIVATE ❑ DRILLED Dia. of Well Casing °F <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of_Grout Seal �'b <br /> . -� <br /> I 11F�� <br /> CATHODIC PROTECTION Lx ROTARY Type of Grout <br /> ❑ DISPOSAL El OTHER <br /> 0 GEOPHYSICAL �,� Other Information <br /> w t Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor�C� �i 5.d .� <br />€- Type of PumpY. H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done. " <br /> PUMP REPAIR: ❑ State'Work Donet i <br /> DESTRUCTION OF WELL: Well Diameter''f, <br />�. Approximate Depth <br /> I# t Describe Material and Procedures <br /> I hereby certify that.l have prepared this application and-that the work,.wil1-be`dpne in'accordance with San Joaquin County <br /> ordinances, state laws, and rules,,and regulations of the San Joaquin Local Health District. <br /> Home owner 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X. ��- �,Title:� =- �> _ �_ Date: 711 I <br /> (Draw Plot Plan on Reverse Side) I g t <br /> FOR DEPARTMENT USE ONLY 8 j <br /> PHASE I 1 <br /> Application Accepted B .- �_ �"' <br /> pp p y Date�d <br /> Additional Comments: <br /> Phase 11 Grout Inspection : '� _ ase III Final Inspection _ <br /> Inspection By ��-Date` Inspection By <br /> mate <br /> Fee Is Due::❑~ANNUAL✓-Y ❑ PER UNIT )0 PER SITE ❑ EACH ❑ January 1±&Received By January 31 ❑ July 1 &Received By July 31 I <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE _ DATE REMITTED AMOUNT DUE CHECKED <br /> i AMOUNT <br /> r <br /> FEE <br /> LESS <br /> - <br /> PRORATION <br /> r <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> jj <br /> Received by if Date t Receipt No. Permit No I - f <br /> r P 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 />