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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFQCE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER UALITY <br /> (COMPLETE IN TRIPLICATE)Z2 (, _�, 6 4>tiT r^- Q (3' <br /> Application is hereby made tothe San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Cou y Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address + /Town '' IC <br /> PIM. <br /> Owner's Name Phone <br /> Address 73 4AX eDCity <br /> Contractor's Name �r License s� ._ Business Phon <br /> �. — <br /> # <br /> Contractor's Address '5"ri. - KJ4 _ Emergency Phone - <br /> Is Certificate of Workman's Compensation Insuranceith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL-W DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /it P97 Sewer Lines Pit Privy <br /> Sewaige Disposal Fieldl��✓ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well - ` <br /> INTENDED USE TYPE OF WELL s ' <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 18�DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC i ❑ DRIVEN Gauge of CasingL <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information N . <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done - _ • <br /> PUMP REPAIR: ❑ State Work Done 1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth N <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 /> Home owner orlicensed'agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 7 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I <br /> I will c 1 fo;a Gro 1 Inspection prior to grouting and a final inspection. <br /> Signed X 610-2111 r` Title: <br /> -� Date <br /> I` (Draw Plot Plan on Reverse Side) <br /> I FOR D PARTME USE ONLY <br /> PHASEI e <br /> Application Accepted By Q Date 2 <br /> Additional Comments: <br /> rI <br /> Ph s:l ll Grout Inspection a III Fin tnspection / <br /> Inspection By f Date Inspection By Date o� � <br /> Fee IS Due- ❑ ANNUALLY �❑ PER UNIT PEA SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REWT <br /> BILLING REMITTANCE $ <br /> BASE �^� EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS I erf <br /> PENALTY <br /> OTHER <br /> OTHER I ,� <br /> M „ <br /> 'Received by Oateaf! Receipt No. Permit No. Issuance Date Mailed Delivered <br /> PPLICANT—RETURN ALL COPESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ,� .. - <br />