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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. m _ <br /> FOR OFFICE USE: APPLICATION i <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with an Joaquin Co un Ord' ance o. 1862 and the rules and regulations of the San Acaquin Local Health District. <br /> Exact Site Address + City/Town <br /> Owner's Name P ne2 � r •Z, <br /> Address City <br /> Contractor's Name t { <br /> License# 1 S Business Phone p <br /> Contractor's Address Emergency Phone � c7-�6 9 Z <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r� <br /> WELL CHLORINATION 11 WELL ABANDONMENT 11 OTHER 11PUMP INSTALLATION ❑ PUMP REPAIR❑ L 1 <br /> REPLACEMENT❑ 0 <br /> + r <br /> DISTANCE TO NEAREST: Septic Tank 1 Zd 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 Il <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation 40 Z <br /> �pOMESTIC/PRIVATE ❑ DRILLEDCt <br /> Dia. of Well Casing -fh _ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Z 4.+ur <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout rt7• fi <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �}:�~ <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 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." t <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this f <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c f a Grout i pr' routing and a final inspection. <br /> Signed X <br /> Title: Date: <br /> aw P o Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By d 9— j—$� <br /> Additional Comments: Date <br /> ha II Grout Inspection s�IlFinal Inspection t <br /> Inspection By Date C7 -� � 0-2 <br /> inspection By Date { <br /> t <br /> Fee IS Due: ❑ ANNUALLY 1:1 PER UNIT ❑ PER SITE ❑ EACH ❑ January 4 &Received By January 31 ❑ July 1 &Rec ved By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE nEMITTFD AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> i <br /> Received by 11 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 />