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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TneAppucauon. <br /> FOR OFFICE USE:''' APPLICATION i <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY } <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 with San Joaquin Count Ordinance No. 1 jC2 and the rule and regulations of the San Joaquin Local Health District. <br /> 77 <br /> Exact Site Address r City/Town <br /> r Phone <br /> Owner's Name f. Cit + <br /> Address y " <br /> Contractor's Name Lioense#122tZ_ Business Ghon _ <br /> Contractor's Address <br /> F G Emergency Phone r� <br /> Is Certificate of Workman's Compen ationI urance on File With SJLHD? Yes X— No <br /> TYPE OF WORK (CHECK): NEW WEL DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ } <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 t <br /> Ii <br />` ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation <br /> ❑-DOMESTIC/PRIVATE ❑ DRILLED _ Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> i ❑ IRRIGATION 1:1 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 13 OTHER Other Information W <br /> El DISPOSAL - n <br /> Surface Seal Installed By: <br /> 11 GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ` <br /> ' PUMP REPAIR: 1:3 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> f Describe Material and <br /> 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 /> 1 Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> I 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 v <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a rout inspection pri r to grouting and a final inspection. <br /> .41 <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date /$ 19— <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection 4Ph=lFinal Inspection <br /> p hate Inspection By Date <br /> Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEBlylJuly 31 m <br /> BALING - REMITTANCE AMOUNT DUE CHECKED — <br /> ¢ - BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> Y <br /> L?5n—37— <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 OTHER <br /> F OTHER T . <br /> r <br /> Received 4y Date Receipt No Permit No.; - Issuance Date Mailed Deprfed`s <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1$01 E.HAZELTON AVE.,P.O.BOK 2005 STOCKTON,CA 35201 <br /> va- <br />