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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 Pon-Tref9sferable, Revocable,Suspendable) 00 <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 wl San Joaquin County Ordinance No.. 1,J362 and the rules and regulations of the San Joa uin Lo al Health District. <br /> Exact Site Address�3� 0-- N R-1 ger _ City/Town <br /> ply <br /> Owner's Name hI Phone G+7U "' 0 <br /> Addresses m City 45 C AL40.,- <br /> Contractor's Name - -S:,AL� �_�.�-�" License#.?M/O Business Phone --44 7 <br /> Contractor's Address 2,4D1403 M i,. Emergency Phone �--- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Y e S A-14 No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11 "DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR0 <br /> REPLACEMENT❑ <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 Wel! �n1 <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 ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done _ v S !�� e 544 tr <br /> ' I <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 /> 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 pePformance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call t rou nspecti rior grouting and a Lina! inspection. , <br /> Signed X Title: Date: ��� <br /> (Draw Plot Plan on Reverse Side) <br /> �EPARTMENT USE ONLY <br /> PHASE I � � <br /> Application Accepted By eDate a rd <br /> Additional Comments: <br /> Phase fl Grout Inspection Ph 'e III Final Inspection Z <br /> Inspection By Date Inspection By I Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recei By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ' S <br /> LESS <br /> PRORATION <br /> PLUS ! <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by t Dae Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 �'J <br />