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Applications Will Be Processed When Submitted Properly Completed.Be SureToSignTheApplication. �`' a <br /> FOR.OFF;Jv <br /> CE USE: ( APPLICATION // <br /> r (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ;,. ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and <br /> install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and r gulationnsJof the San Joaqu' Local Health District, <br /> Exact Site Address %V_� 6C$1Y�/L T �i��E�'Y/Town !r, <br /> Owner's Name Phone -5,17`1 — !S <br /> Address city_ 4 Fob <br /> T� <br /> Contractor's Name <br /> License# �_�S ll Busess Phone�� 17?& <br /> �� in <br /> Contractor's Address 425 t � Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 4 J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR© I <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ' Sewer Lines ( <br /> - 4z Pit Privy <br /> Sewage Disposal Field s r '{ Cesspool/Seepage Pit Other <br /> I. <br /> Property Line Private Domestic Well_S2 Public Domestic Well <br /> J <br /> INTENDED USE TYPE OF WELL <br /> ABLE TOOL Dia. of Well Excavation <br /> 0 INDUSTRIAL A� <br /> ElDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing p <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> A-IRRIGATION 11GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �I <br /> ❑ DISPOSAL ❑ OTHER Other Information -y <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ��Qc-eawE f <br /> PUMP INSTALLATION: Contractor V <br /> Type of Pump N.P: <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work DoneA I <br /> roximate Depth A <br /> DESTRUCTION OF WELL: Well Diameter pp <br /> Describe Material and Procedure <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rulesjand regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent'sisign ature certifies the following:"I certify that in the performanceof 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, rsons subject to workman's compensation laws of California." <br /> I call for Gro ns prior to grouting and a final inspection. i <br /> Signed X Title: Date: <br /> i (Draw Plot Pian on Rever Side) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I 1 ®� Date , <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection JPhase III Final Inspection <br /> r inspection By Date Inspection Dated By <br /> ` <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ElJanuary 1 &Received lay January 31 ❑ July 1 &ReceiveREMITUIy 31 ) <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 1 <br /> FEE <br /> LFSS <br /> PRORATION i <br /> PLUS <br /> PENALTY s <br /> OTHER <br /> OTHER <br /> 13 cz <br /> Received 0y Date Receipt No - Permit No Issu nce bate -Mailed Delivered <br /> -. APPLICANT—RETURN ALLCOPIESTO: 'k ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 952 <br />