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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F01 OFFf-E6SE: APPLICATION <br /> ,r (for Non-Transferable, Revocable,Suspendable), PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br />• (COMPLETE IN TRIPLICATE), WATER QUALITY i <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 witU Span oaquin County Ordnance N . 1862 and a rules and regulations of the Sa JOaq in.)Local Health District. ] <br /> Exact Site Address 4 Ki ynqLD City/Town O / <br /> ` 6 34e 0 15 aS <br /> Owner's Name �f a� �.! Phon + � <br /> Address + O City + <br /> Contractor's Name r✓ i• nLicense# 7'97VBusiness Phone +r <br /> Contractor's Address DO V("+ ~Dt . Emergency Phone <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes ✓ No I <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO ❑ <br /> WELL CHLORINATION C3 WELL ABANDONMENT 13 OTHER E] PUMP INSTALLATION/ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> u Property Line - Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ti <br /> v <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation + <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ly .lMe�✓ - __ <br /> 0 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IIIA IRRIGATION ❑ GRAVEL PACs( Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout j <br /> ❑ DISPOSAL ❑ OTHER Other Information " <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �1'l <br /> PUMP INSTALLATION: Contractor - -- "" <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: ❑ State Work Done T' <br /> PUMP REPAIR: ❑ State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> x _ <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 /> I! - Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> pis 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X �&elvlez '• ,i = _ Title: Date: <br /> (Draw Plot Plan on Reverse Side) r <br /> FOR DEPARTMENT USE ONLY <br /> t' PHASE 1 '^ Jiyr/" <br /> Application Acceptey Y" Date I y <br /> Additional Comment <br /> P a It Grout Inspection Ph s .III Final I e - <br /> Inspection By Date Inspection By m - Date 3' <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - <br /> AMOUNT <br /> FEE ..► <br /> LESS <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ,F <br /> L�.A66PPLICA <br /> wed by - Date - Receipt No. - ermit No. --- Issuance Date, ,_.Mailed�` Delivered <br /> NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 i <br />