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Applications Will Be.Processed When Submitted Properly Completed. BeSureTo SignTheApplication. <br />^ FOR oFFlce use: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> M (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> M, Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wit o r� dd\\ �dinnanc Ne+/�8�62 and the rules and regulations of the Sar qu'LLpr Health District, r <br /> Exact Site Address a �LJJCity/Town /� <br /> I 943i <br /> Owner's Name u + Phone ` <br /> [, City <br /> Address .�f 2" rill <br /> Confractor's Name CG W�. p icense# Busine s Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation In rance on File With JLHD? Yes ;No w <br /> TYPE OF WORK {CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ /''� � <br /> DISTANCE TO NEAREST: Septic Tank ����+/ Sewer Lines Pik Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property tine —lF�/ —Private Domestic Well Public Domestic Well <br /> F INTENDED USE TYPE OF WELL s �/ <br /> ❑ I STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 111 $ �" <br /> � f <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ehdd <br /> fk ❑ DISPOSAL ❑ OTHER Other Information <br /> E] GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor f <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 L <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 /> permi I issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w' c I for <br /> out In ectio or to g outing and a final in 8 Q <br /> Signed X Title: Date:` <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 0-0 <br /> r v Date " <br /> Application Accepted By <br /> Additional Comments: <br /> Phe ll out Inspection] 'Phase 111 Final Inspection <br /> Inspection By Date d" Inspection By Date <br /> PER UNIT ❑ PER SITE ❑ EACH El January 1'&Received By January 31 ❑ July 1 &.Received By July 31 <br /> Fee IS'Due:-❑ ANNUALLY ❑ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $�; AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> Lo <br /> FEE C <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> 10 <br /> I <br /> E' Received by Date 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 />