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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 <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 aq C u ty Ordinance No.1 62 and the rules and regulations of the San oaqui Local He a District. <br /> Exact Site Address �L�'' '�G y �dl �? 1" City/Town <br /> + I <br /> Owner's Name r �` Phone l¢ :112i <br /> 'Address _A City d <br /> Contractor's Name License# Business Phone 2 Sr 1?2 <br /> Contractor's Address d Emergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance on Filit With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ 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 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 I <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ C,EOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: kontractor `A_ <br /> �Type of Pump d f H.P. } <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:N 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 shall employ persons subject to workman's compensation laws of California." <br /> I will for a Grout ns ectio for grouting and a final inspection. <br /> Signed X-.. . .—i Title: --- P� r .� G Date: '" r- eq <br /> (Draw Plot Plan on Reverse Side) <br /> F R D ARTM T USE ONLY <br /> PHASEI <br /> Application Accepted By 4 Date*/�ZYO <br /> Additional Comments: <br /> Phase II Grout Inspection a III F€ Inspection <br /> Inspection By Date Inspection B Date <br /> Fee Is due: El ANNUALLY ❑ PER UNIT 07PER SITE El EACH El January 1 &Received By January 31 ❑ July 1 $,Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE MOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE "f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Gv1C4I S B a o �-- <br /> Received by Date k Receipt No. Permit No. Issuance Date - Mailed Delivered - <br /> E APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.121 STOCKTON,CA 95201 {I <br />