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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheApplication. <br /> FOR OFFICE USE: ' APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> S ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)!1(0-777 S. y4rcJL14�7� TER QUALITY <br /> ` Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install thd work herein described.This application is <br /> f made in compliance with San Joaquin County Ordina ce No. 1862 and the rules and regulations of the San Joaquin Local Health Dista t. <br /> I Exact Site Address v 1 F U G City/Town 00 �iFo,P�Ji <br /> Owner's Name L. �' E l�G Phone 8 <br /> Address d. D } City <br /> Contractor's Name , - LE r a1 t License# �� Business Phone 45 4 <br /> Contractor's Address 3i� 5` c4-72�1Emergency Phone _ �— <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No r– <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 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> i <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ' ❑ DOMESTIC/PRIVATE 2KDRILLED Dia. of Well Casing At <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal e/ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> I <br /> © <br /> DISPOSAL 13 OTHER Other Information <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done - 1 <br /> PUMP REPAIR: ❑ State Work Done <br /> I DESTRUCTION OF WELL: Well Diameter Approximate Depth h <br /> Describe Material and Procedure C <br /> l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> If ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I <br /> Homeowner or licensed agent's signature certifies the following:°I certify that in the performance ofthe 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 4 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prix to grouting and a final inspection. <br /> I Signed X KL E{ Title: Date: <br /> i F _ (Draw Plot Plan on Reverse Side) <br /> � I <br /> jF FOR DEPARTMENT USE ONLY <br /> PHASE I L6 <br /> Application Accepted By Date <br /> Additional Comments <br /> Phase 11 Grout Inspection ase 111 Fi Inspection <br /> Inspection By Date Inspection 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 /> BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � �� � _14-2-5� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> Received by Date x Receipt No. Permit No Iss ante D to Mailed Delivered <br /> # APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />