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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -'FOVOFFICE USE: APPLICATION <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 fora permit to construct and/or install the work herein described.This application is <br /> made in compliance w th San Joaquin CounCt+y Ordinance qo. 186 nd a rules and regulations of the Sa Joaquin Local He a h Di tr� �� <br /> Exact Site Address / © 5 C7 City/Town f �Q I <br /> Owner's Name '/A V47 A-7 L !�,APhone �— 3 � � <br /> Address City <br /> Contractor's Name License 410s"Business Phone�9 31-/0 7.3 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION Pr PUMP REPAIR❑ %14 <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy (�J <br /> Sewage Disposal Field Cesspool/Seepage Pit Other_ <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 0 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r� <br /> Type of Pump 6 ea lipH.P. 3 -+- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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, and rules and regulations of the San Joaquin Local Health District. <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 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 �-'-- <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I all for a Gro t Ins actio prig to grouting and a final inspection. C <br /> Signed X Title: t ;` Date: <br /> (Draw Plot Plan on Reverse Side) <br /> s <br /> { FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By L Date <br /> Additional Comments: <br /> Phase II out Inspection se I Find Inspection �1 <br /> Inspection By . Date I Inspection By Date 1�J�73 <br /> Fee Is Due: ❑ ANNUALLY4"+ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31.. ❑ July 1 &Received By July 31 <br /> h l + %KREMIT <br /> BILLING REMITTANCE i;rs <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 1 i <br /> PLUS <br /> PENALTY �L W <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTO A E.,P O.7B 2007 STOCKTON,CA 95201 <br />