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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County.grdin t ules a r gu ations of the San JoaqL#gLocaI Health District. <br /> Exact Site Address M4 JPTown ��- <br /> Owner's Name LGI040 f/ rrzk., Phone <br /> Address �S�'��9 �+✓t�l��t ea City— <br /> Contractor's Name `i &F4Wt—&,nw 7190 License# Business Phone G 7 L <br /> Contractor's Address d #- Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wid SJLHD? Yes—X No ^�� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® 1 <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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> OL IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL / Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump 01 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> Al <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 /> 1 w 11 call for a Grout Inspe npr' r 'gro 1 g an final inspection. x�tf <br /> Signed Itle: r Date: <br /> (Draw Plo Ian on Reverse Side) <br /> (� FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By �J Date 0 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> Inspection Byhf/ADate Inspection By -2W, 911'1— Date ld <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 $ IMA#- AMOUNT DUE CHECKED <br /> DATE DATE REMI*W AMOUNT <br /> l FEE wo f r I C41" <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 <br /> Received by Date Receipt No. Permit No. Idsuanct Date I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />