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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> " <br /> FORrOFFICE USE: } APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> .--,, ,i PUMP&WELL <br /> ENV IRONW#ENTAL HEALTH PERMIT w <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 Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town > <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name +� License ft IZ.�,37' Business Phone 9ig..2S <br /> Contractor's Address u Emergency Phone <br /> Is Certificate of Workman's Compensation Ins nce on File Wit HR? Yes No r- <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITJON❑ DESTRUCTION❑ --T" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑� -PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ r' -- <br /> DISTANCE TO NEAREST: Septic Tank Sewer•Lines Pit Privy T 4 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well —Public Domestic Well <br /> INTENDED USE ' TYPE OF WELLPf,4- <br /> ❑ INDUSTRIAL ❑ CABLE.TOOL � ,, Dia, of Well Excavation <br /> ❑ pRILLED ; >Dia. of Well Casing <br /> L�DOMESTIC/PRIVATE aK�+x � � � ,k:< � 9 <br /> ❑ DOMESTIC/PUBLIC RIVEN i Gauge of Casing <br /> 13 I'RRIGATIO' N' WGRAVEL PACK­"­��Depth-of Grout Seal <br /> ❑:CATHODIC PROTECTION ❑ ROTARY Type of Grout O <br /> { ❑ OTHER "' =-€Other Information J ,` <br /> ❑ DISPOSAL _ <br /> ❑ <br /> GEOPHYSICAL s^ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor I <br /> �1 i.P. {,. <br /> -.Type of Pump <br /> PUMP REPLACEMENT:, State Work Done- - - - <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 7 I <br /> S i 5 <br /> Describe Material and Procedure <br /> - I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i ordinances, state laws, and rules and regulations of the Sawn 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 /> J <br /> is ' ued, I 11 not employ any person ins h manner as to become subject to workman's compensation laws of California." <br /> _4" r <br /> ontractor's h! ng or sub-contract' g si to certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is sue , I shall employ su ect to r man's compensation laws df Cali.fornia." <br /> 1 wil a out Ins c' Ing nd a final inspecti Sys <br /> + i -� <br /> Signed X Title:. � Dale: <br /> (Draw Plot Plan on: everse,Side) = f <br /> it FOR DEPARfTiNENT USE ONLY t s n <br /> PHASE ! <br /> Date - <br /> Application Accepted By <br /> Additional Comments: € �- <br /> Phase If Grout Inspection i P� III Final Inspection ' <br /> Inspection B _.& Date g'-�o Inspection .By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &.Received ByJanuary 31 ❑ July 1 &Received By July 31 . <br />+ 3i REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE AMOUNT ix <br /> DATE DATE REMITTEE <br /> FEE rti -r <br /> LESPLUS <br /> " <br /> PENALTY <br /> �..._% ,•��t w 'q�. <br /> . OTHER <br /> OTHER <br /> Received by Date Receipt No. PermitNoIssuance Date Mailed Delivered <br /> 601 E.HA2ELTON AVE.,P.O.Box 2000 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 . <br />