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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) <br /> � <br /> ENVIRONMENTAL HEALTH PERMIT- <br /> PUMP&WELL(COMPLETE IN TRIPLICATE) WATER QUALITY N <br /> f <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County t'Ordinance No. 1862 and the ruleja regulations of the San Joaquin Local Health District. <br /> Exact Site Address �+�� y /A) xC? �L liJ 5 t5 ! i1 City/Town <br /> Owner's Name f _ Phonel <br /> Address City <br /> Contractor's Name CeM A C� V4 C)� '!:,'S 4� Ami License#a 3 Business Phone " t <br /> Contractor's Adc"516:6Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes *. No <br /> TYPE OF WORK (CHECK): NEW WELL M-'~ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATIONS PUMP REPAIR❑ Q <br /> REPLACEMENT❑ _ <br /> DISTANCE TO NEAREST: Septic Tank '/S L` Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ` t <br /> Property Lindrbts Private Domestic Well Public Domestic Well F <br /> INTENDED USE TYPE OF WELL <br /> ❑ INgUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation pe <br /> ®DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 9 !'fOfARY Type of Grout 9!.2 ac- Or, <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL *t- Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor [ ��/ Eta r"' P <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> 11 '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. o <br /> Homeowner or licensed agent's signature certifies the following-"1 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:1 certify that in the performance of the work forwhich this 4 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." S <br /> t / � <br /> 1 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> F �DEP TMENT 5E ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> s II OrOU spection / n Pha e I Final Sspectio <br /> Inspection By Date (p L� Inspection By � Date e f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNI PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE D f � <br /> ji <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER k <br /> ? L,3 I It I, <br /> Received by /Datelf Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />