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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. Y <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferabie,Aevocable�Suspendable) <br /> f 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 permitto construct and/or install the work.herein described.This application is <br /> made in compliance with San Joaquin Co u ty Ordinance No. 1862 a d the rules and.regulations of.the Sa Joaquin Local Health..District. <br /> Exact Site Address J (L / / 4 <br /> Owner's Name , City/Town <br /> Address � � Phone C 3rFo�i`�f�- <br /> o <br /> Contractor's NameCity License# 5Business Phone <br /> ressOMY <br /> Contractor's Add <br /> sfQ p" <br /> � <br /> 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 PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /S-0 Sewer Lines S� Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well X_— Public Domestic Well <br /> INTENDED USE TYPE OF WELL y <br /> INDUSTRIAL XCABLE TOOL Dia. of Well Excavation 1 Z' <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ld <br /> ❑ IRRIGATION Cl GRAVEL PACK Depth of Grout Seal _:!�-e <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout -AJ2� L'P�rx�u-><t� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor d <br /> Type of Pump G H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter, t ' <br /> ° Approximate Depth ��v <br /> Describe Material and Procedure <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San 7sperm <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 performanceofthe work for wis issued, I shall not employ any person in such manner as to become subject to workman's compensation lawContractor's hiring orsub-contracting signature certifies the following:"I certifythat in the performanceof the wot <br /> a�. permit is issued, I shall employ persons subject to workman's compensation laws of California." u <br /> I wpea-11yoraFut nspection prior to grouting and a final inspection. <br /> Signed X _�.c-C-G� Title: Date: !e <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY F� y <br /> PHASE I j <br /> Application Accepted By <br /> Additional Comments: Date <br /> Phase II Grout Inspection Pas Final Inspection <br /> Inspection By Date g�' Inspection By Date 4�- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1'&Received By July 31 1 <br /> 4 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION - $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT ' <br /> FEE 4 �.' p <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY + } <br /> OTHER F <br /> OTHER <br /> Received by - - ate- - Receipt No. Permit No. - I <br /> ssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 1 <br />