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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication. <br /> '06 dfFICE USE: APPLICATION <br /> ti (For Non-Transferable, Revocable, Suspendable) <br /> 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 with*San iJo uin Co u y Ordin e No. 1862 and the r les and regulations of the S n Joaquin Local Health District. 0 <br /> Exact Site Address _ ! 1 � {T /��/t/!�N1. B� City/Town <br /> r <br /> Owner's Na e,. Phone L <br /> AddressCity 1 <br /> Contractor's Name icense#I Business Phone �! <br /> Contractor's Addressel 12A,Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes r No <br /> TYPE OF WORK (CHECK): NEW WELLO DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank AV Sewer Lines / f1 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> r <br /> Property Line � Private Domestic Well_ � Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑�p CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE +DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing o <br /> ❑ IRRIGATION I&GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout `ry✓lCit�k/� <br /> ❑ DISPOSAL ❑ OTHER Other Information ` N <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1`" H.P. n. <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 /> 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. a <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof thework 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 shall employ persons subject to workman's compensation laws of California." <br /> I will call for arGrout Inspection prior to grouting and a final inspection. <br /> Signed Xt� Title: /rT7!l"1_t.Anwi Date: " <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �,�{ <br /> Application Accepted By_ i 1 04,5 Datza-'Oc>- <br /> Additional Comments: <br /> Phos I Grout Inspection Phase III Final Inspection <br /> Inspection By Date :Z, $ Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January-I &Received By January 31 ❑ July 1 &Received By July 34 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED - <br /> AMOUNT <br /> FEE "a 00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. ssuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />