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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign.The Application. <br /> FOR-OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT 4 <br /> (COMPLETE IN TRIPLICATE) <br /> WATER-QUALITY /_v <br /> Application is hereby made to the SanJoaquznLocal Health District-for apermit to constructand/or install the work herein described.This applicationis� <br /> made in compliance with San Joaquin County Ordinance_ No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address & � � City/Town JA..19±1.- <br /> Owner's Name - Phone <br /> Address City ZL!1.4 > <br /> Contractor's Name =License#33ar�(-7/ Business Phone &3�-].<Y!Y <br /> Contractor's Address d ' Emergency Phone <br /> Y <br /> Is Certificate of Workman's Compensation Insurance on File ith SJL-HD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ +I <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 4 <br /> INTENDED USE TYPE OF WELL Q <br /> ❑ INDUSTRIAL k ❑ CABLE TOOL Dila. of Well Excavation N <br /> DOMESTIC/PRIVATE ; ❑ DRILLED Dia. of Well Casing [.3 <br /> ❑ DOMESTIC/PUBLIC s ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION! ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL t ❑ OTHER (.Other Information - <br /> ❑ GEOPHYSICAL 1 wLL �-• - - � -�— ^ - -'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .4-c.c.6 t H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done f <br /> DESTRUCTION OF WELL: Well Diameter ! Approximate Depth <br /> Describe Material and Procedure i <br /> `i he eby certify that have prepared this application and that the work will be done yin accordance with San Joaquin County <br /> -- ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> _' <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'coftipensatioh 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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will Grout Ins ection prior to grouting and a final Inspection. <br /> Signed JC Title: Date: <br /> 1 (Draw Piot Plan on Revveerse'Side) I k <br /> FOR DEPARTMENT USE ONLY j <br /> r <br /> PHASE I } <br /> Application Accepted By ; " ' Date <br /> Additional Comments: <br /> Phasejll Grout Inspection Phase Il Final inspection 1 i <br /> Inspection By x Date Inspection By # ate11-T $ '¢ <br /> Fee IS Due: ❑ ANNUALLY - [D PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January,?31§.y,❑,July s•&Received By July 31 <br /> P! BILLING REMITTANCE 1$ REMIT <br /> BASE i EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> i AMOUNT <br /> FEE Gj ` [ `7� 1 <br /> LESS / <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 96 <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Pelivered ; <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,C <br />