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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: II' APPLICATION <br /> II <br /> ' (6 � (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL-HEALTH PERMIT PUMP&WELL <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,Joaiquin County Ordinance No. 1862 and the rules and regulations of the San Joaquuin'Locai Health District. <br /> Exact Site Address ts0 k) City/Town a- P <br /> Owner's Namek4n6&2 d Phone <br /> Address _ 1 "1- D City <br /> — 1CD44 <br /> Contractor's Name 'I !� r AL3 License Business Phoneb — 26 7 l <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No r <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ` <br /> f WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR. <br /> L REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ Sewer Lines Pit Privy <br /> p Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL I ❑ CABLE TOOL Dia. of Well Excavation <br /> I ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> s ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I / Surface Seal Installed By: <br /> PUMP INSTALLATION: I i Contractor <br /> Type of Pump _77b-LhtH.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done � c/YG 4a v 057 <br /> r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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,l�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 shat.employ persons subject to workman's compensation laws of California." <br /> II call for a Grout I Inlspection p r 1 ro nd a inal inspection. <br /> Signed "I Itle: <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> " <br /> PHASEI C <br /> i <br /> Application Accepted By -�� ct'4Q_H�+ ._. Date � q <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phipse III Fi al Inspection <br /> Inspection By �� Date Inspection ByDate -7— �p <br /> i <br /> Fee Is Due: ❑ ANNUALLY �I'E] PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I REMIT <br /> BASE `I EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS l <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> y i <br /> OTHER - <br /> i <br /> OTHER <br /> i <br /> Received by Date'III Receipt No, Permit No. suance ate Mailed Delivered I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201 <br />