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i <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> FOR OFFICE USE: APPLICATION <br /> (Far Non Transferable, Revocable, Suspendable) ' <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I <br /> (COMPLETE IN TRIPLICATE} WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install the work,herein described.This application is <br /> made in compliance wityv!�Crjf <br /> un O ce No.1862 and th rul d regulations of the San a Local eh District. <br /> Exact Site AddresCity/Town e C �C 6 �� <br /> Owner's Name . A'�, �� Phone <br /> Address it City <br /> Contractor's Name L �- License# %WA�busiqess Phone <br /> Contractor's Address C Emergency Phone ) <br /> + Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes- X No d <br /> TYPE OF WORK (CHECK): NEW WELL)i DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f,1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ [! <br /> REPLACEMENTIF <br /> I DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy. <br /> Sewage Disposal Field Cesspool/Seepage Pit /10 � Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL e� <br /> ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation et <br /> f '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 ROTARY Type of Grout op <br /> W � d <br /> C] DISPOSAL 1:1 OTHER Other Information aDG <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 0. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: X State Work Done =F --� <br /> PUMP REPAIR: ❑ •State Work Dones <br /> I DESTRUCTION OF WELL: i Well Diameter- <br /> Describe <br /> iameter Z Appro'�IAmate Depth <br /> �t l G� c f f1 <br /> Describe Material and Procedure G-.. <br /> y I hereby certify that 1 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 /> 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w- r a Grout Inspection 'or to gr ting a final inspection. 57 <br /> Signed Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY '1112 ty &,.-//�i/7►-0 <br /> PHASE I q4"- <br /> Application Accepted By Date <br /> Additional Comments: <br /> hase II trout Inspection Kase III Final Inspection,/ r 3�O Z� <br /> Inspect' <br /> By Date 1 Inspection By Date `l- <br /> r <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 /> QQ DATE DATE REMITTED - AMOUNT <br /> t <br /> V <br /> FEE � C Q 0-ca <br /> v <br /> LESS <br /> PROBATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C, S <br /> t o� <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />