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Applications Will Be Processed When Submitted•Properly Completed. Be Sure To Sign The Application. �l f <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETEINTRIPLICATE)= ;.. - t ': "' "s'" ' 'f • r <br /> Application ishereby made tothe San JoaquinLocal Health District forapermittoconstruct and/or.instaIIthework.here Indescribed.Thisapp Iicationis i <br /> made in compliance with San Joaqui Cou Ordin nce No. 1862 and he rules and regulations of the San Joaquin Local Health District. i <br /> Exact SitefAddress City/Town - r <br /> # Phone.3 4. R `7. T <br /> Owner's Name City <br /> Name Address _. <br /> Contractor's Nam ' License#1(..2 37 = Business Phone <br /> "Emergency - Cs <br /> 1 ' Phone <br /> Contractor's Address 9 y t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes ►� No " <br /> TYPE OF WORK (CHECK): . NEW WELL❑ "�' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER-C] PUMP INSTALLATION S— PUMP REPAIR®' <br /> REPLACEMENT❑ u' <br /> DISTANCE TO NEAREST: Septic Tank e Sewer Lines Pit Privy <br /> j Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL t " <br /> ❑ INDUSTRIAL CABLE TOOL Dia, of Well Excavation <br /> ❑ <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ° �! <br /> �❑,/Q S7PtBLIC 5 11 DRIVEN Gauge of Casing <br /> 'IRRIGATION ,a ❑ GRAVEL PACK Depth of Grout Seal I ' <br /> b ❑ ROTARY Type of Grout <br /> ❑'CATHODIC PROTECTION j b <br /> ❑OTHER ''Other In ormation -" '- <br /> ❑DIS OSAL ___ <br /> ❑ GEOPHYSICAL - Surface Seal nstalled By: <br /> PUMP INSTALLATION: Contractor 49 <br /> i ► <br /> Type of Pump ! ► H.P. <br />' ❑ State Work Done i <br /> PUMP REPLACEMENT: , l <br /> PUMP REPAIR: t ❑'State Work Done j <br /> DESTRUCTION-OF WELL: : Well Diameter tI Approximate Depth <br /> rx Describe Material and Procedure . <br /> r� { <br /> 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 Lo al 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 hiringnor 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." i <br /> I ; <br /> (,.will 11 to .a Grbut-Ire ection.prior_o.grouting and a final..ins on., - <br /> Signed Xi <br /> tle:. erses SiDate: I/ <br /> (Draw Plot Plan on Revde} <br /> i FOR DEPARTMENT USE,ONLY <br /> PHASE j <br /> Application Accepted By F Date "T <br /> Additional Comments:i . <br /> „Phase 11 Grout Inspection r y ha III Final Inspection _62 <br /> t <br /> .Inspection By I Date Inspection By <br /> ( Date <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 /> r i BILLING. REMITTANCE $ NSOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTEDAMOUNT <br /> t 04 <br /> FEE �- <br /> "LESS <br /> PRORATION <br /> eo <br /> PLUS l <br /> PENALTY r .� <br /> OTHER <br /> a <br /> OTHER <br /> t <br /> Received by <br /> -'Date - Receipt No. Permit No. - Issua ce ate Mailed Delivered - - <br /> 5241 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1607 E.HAZELTON AVE.,P.O.6o:2009 STOCKTON,CA 9 � <br />