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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFI E use: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELD° <br /> ENVIRONMENTAL HEALTH PERMITS <br /> yyATER QUALITY -4 04 411a­x- d 2 /tee h a nc as 4 <br /> (COMPLETE IN TRIPLICATE) { (?' S- i`-Fel--s°�-O <br /> Application is hereby made to the San Joaquin Local Health District fora permitto 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 1.�y%%•rte Pf- AI!► &a A all City/Town <br /> Owner's Name ` f Phone <br /> Address /." City <br /> Contractor's Name License# Business Phone <br /> f1& 67 <br /> Contractor's Address f Emergency'Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No w^ OO OO <br /> TYPE OF WORK (CHECK): NEW WELLJZ DEEPEN C1 _RECONDITiON 13DESTRUCTION❑ <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 /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �r <br /> Ky--INDUSTRIAL���r+a i esYr 13 CABLE TOOL Dia- of Well Excavation , <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing n <br /> i ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing" <br /> ❑ IRRIGATION 151 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ® ROTARY Type of Grout 's <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> a <br /> j PUMP INSTALLATION: Contractor Ir <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done Approximate ��j1 <br /> I <br /> DESTRUCTION OF WELL: Well Diameter A pp Depth - rJ <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 /> i <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 /> 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 fqf a Grout Inspection prior to grouting and a final inspection. <br /> jam` <br /> Signed X9"� " <br /> _ Title: �s Date: <br /> k (Draw Plot Plan on Rev rse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By v Date <br /> Additional Comments:. l <br /> P ase 11 Grout Inspection y _ P se III. Final Inspection <br /> Inspection By <br /> v Date r �f° 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 /> BASE EXPLANATIONS BILLING REMITTANCE S' AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE' <br /> s s � <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> 1121 <br /> Received by I Date - r Receipt No. Permit No, Issuance Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />