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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .FOAYP FFICE USE: t APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> �- -" - PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t (COMPLETE IN TRIPLICATE) t WATER QUALITY ' <br /> Application is hereby made to the San Joaquin Local Health Distric t for a permit to construct and/or install the work herein described.This application is <br /> made in compliance wi h SarLJoagyrin C u Ordinance No. 1862 and the rules and regulations of the-Sr-Jir9quin Local Health District. <br /> Exact Site Address ` City/Town <br /> Owner's Name eep Phone <br /> Address City ] C/Ci`V_'1' 1 <br /> Contractor's Nam Grp-: License # Business Phone -76 `f�� 7 <br /> Contractor's Address/Z�,��Al-jvk P:f-e_Zo;r/J7A;-,t-1.finerg ency 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❑ t <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 Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> KDOMESTIC/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 S rface Seal Ins ta ed By: <br /> PUMP INSTALLATION: Contractor ��cy`J CE/22 - , <br /> t � <br /> Type of PumpH.P.. `. <br /> PUMP REPLACEMENT: EI State Work Done-- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter rApproximate 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 /> P Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> K. 'all, <br /> d, I shall employ persons subject to workman's compensation laws of California." <br /> r a Grout Inspection a.o ,o gro ting and a final inspe n. �' <br /> ~ Signed X � Title: Date: i <br /> (Draw Plot Plan on Reverse Side) ? <br /> f, <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE IAV� <br /> Application Accepted By �` Date 41 <br /> Additional Comments: { -J ` <br /> Phase 11 Grout Inspection �' (Phase III f=inal Inspection <br /> Inspection By &N Date Inspection By - Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ - <br /> BASE EXPLANATION DREMITTED AMOUNT OUE CHECKED <br /> ATE DA <br /> I AMOUNT <br /> FEE IggSOD ) 's f� <br /> LESS , <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER / y <br /> OTHER - - - <br /> 1 <br /> Received by Date Receipt No. Permit No. ssuance Date Mailed Delivered a <br /> V APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />