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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> r Y' (For Non-Transferable, Revocable, Suspendable) <br /> PUMA&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework 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 _r,6 5Q. City/Town c <br /> Owner's Name f 5' �/� Phone 5;r/ A 9 7 67,:-9-3 <br /> Address City <br /> Contractor's Name t G'! License#a 6 r,• Business Phone <br /> Contractor's Address VCWV ,t>rmergency Phone c <br /> Is Certificate of Workman's Compensation Insurance n File With SJLHD? Yes i- - No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION M— PUMP REPAIR 13 <br /> REPLACEMENT❑ P f <br /> DISTANCE TO NEAREST: Septic Tank 16 7L- - Sewer Lines ,��' Pit Privy r <br /> Sewage Disposal Field / 3 L1t- Y" - Cesspool/Seepage Pit Other i <br /> Property Lined Private Domestic Well Public Domestic Weil <br /> INTENDED USE TYPE-OF WELL w <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 91-lZMESTIC/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 �h <br /> ❑ DISPOSAL ❑ OTHER Other Information �} <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor fill Ve c✓ -t 3 } <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 /> 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 i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspe n prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date ( v <br /> Additional Comments: <br /> Phase II Grout Inspection P I inal Inspection <br /> Inspection By Dated Inspection By - Date <br /> f Fee IS Due: ❑ ANNUALLY ❑ PER UNIT YJ PER SITE ❑ EACH ❑ January 1 8 Rec ed By January 31 ❑ Ju1y 1 &Received 8y July 31 <br /> REMIT <br /> BASE EXPLAN TION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> �� II <br />( LESS <br /> PRORAT40N <br /> PLUS <br /> PENALTY <br /> YY OTHER <br /> OTHER <br /> J 6-71 <br />!` Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> f - APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> - 1 � <br />