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J:. <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> EOR OFFICE USE: APPLICATION <br /> (For Nan-Transferable, Revocable;Suspendable) PUMP&WELL s' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> S <br /> {COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is ; <br /> made in compliance with San Joa u.n Counet trdi ante No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address SS City/Town o 0 Ar <br /> Owner's'Name -rA�L&–_s Phone <br /> Address At IfdCity <br /> Contractor's Name License# Business Phone !y '2 UO ; <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insuranceon File With SJLHD? Yes -X._. 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 r� { Pit Privy T <br /> Sewage Disposal Field (3-�� Cesspool/See page Pit Other <br /> Property Line/6 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 1 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �t <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> sc- <br /> El IRRIGATION GRAVEL PACK Depth of Grout Seal s ILL [ <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout _ ag,�>i�aA[ � <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 "� 4 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j <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 performance of the work forwhich this <br /> permit is issued, I shall emplo persons subject to workman's compensation laws of California." <br /> I call for a G f In ec on prior to grouting and a final inspection. <br /> Signed Title: Date: ;Z/, SA,, 1l <br /> (Draw Plot Plan on Reve4 Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> l <br /> Application Accepted By Date � <br /> Additional Comments: <br /> Phase II.Grout Inspection Phase II .F'n ! Inspection p <br /> Inspection By Grp 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 i <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> p I <br /> FEE t- I <br /> LESS �^ f <br /> PRORATION ' <br /> PLUS y <br /> PENALTY i <br /> OTHER <br /> 1 <br /> OTHER <br /> sal [ <br /> Received by Date Receipt No. Permit No. v. Issuance Date Mailed Delivered <br /> APPLICANT ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 I <br />