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Applications Will Be Processed WhenSubmitted Properlycompletes. tie sure io sign Ine►appiicxliivn <br /> APPLICATIONCa �L� lak (For Non-Transferable, Revocable,Suspendable) PUMP &WELLEn <br /> L <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 with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San`J�oaquin Lapa Health Di t. <br /> Exact Site Address �' t City/Town o�+ �C � L <br /> Owner's Name U r2tr_a Phone <br /> Address 5 9f ; sSZy /oma city <br /> Contractor's Name License#/R.3 ��Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on With S -FID? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIRS `— <br /> REPLACEMENT❑ r'n <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy V 1 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well r <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 I] ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seaypsta <br /> Jed By: <br /> PUMP INSTALLATION: Contractor �� 4p4.ow 141 <br /> r <br /> Type of Pump �LH.P. '�� 61 <br /> PUMP REPLACEMENT: State Work Done T G� ✓o <br /> PUMP REPAIR: ❑ State Work Done <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 performance 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 for a Grout Inspect'a ri to grout) and a final inspection. <br /> Signed �� itle: Date: 1i I <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / Date�� <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection /,� P sI Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r FEE c <br /> 4V <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Oate Receipt No. Permit No. I ssuanco Datd Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />