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-II ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 1 'J <br /> FOR OFtC ,USE: 11 <br /> ] APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> `IV ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> ! (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 a d the rules and regulations of the San Joaqul Loca ealth District. <br /> i Ex TaIct Site Address tv 3 / Gt�.g� r�Dp City/Town � <br /> Owlner's Name Ig 0 Phone <br /> Adress �atr�arf City t <br /> con <br /> .! ractor's Name "'tea License#� 7?-. — Business Phone ( C <br /> Co i tractor's Address A Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fil With SJLHD? Yes .— No T- <br /> s <br /> WELOF WORK {CHECK}: NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> L CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR J <br /> REPLACEMENT❑ <br /> k DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> I i Sewage Disposal Field r *Cesspool/Seepage Pit Other <br /> a <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> I ❑ INDUSTRIALI C1CABLE TOOL Dia. of Well Excavation <br /> { DOMESTIC/PRIVATE ❑ DRILLED Dia: of Well Casing <br /> ❑ DOMESTIC/PUBLIC I ❑ DRIVEN Gauge of Casing <br /> c ❑ IRRIGATION I ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I� ❑ ROTARY Type of Grout <br /> El ❑ OTHER Other Information <br /> Cl GEOPHYSICAL <br /> „ Surface Seal Installed <br />€ PUMP INSTALLATION: (( �i Contractor1-d a;. , <br /> Type of Pump <br /> */!,djrELf t�96 H,P. <br /> PUMP REPLACEMENT: it State Work Donefo�.rli� <br /> PUMP REPAIR: i ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r ! <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,1.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 <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 sU' b-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 w'llca!!for a Grout Inspeclio rior o outin and inal inspection. <br /> Signed <br /> :I itle: tate: 11 <br /> II (Draw Plot Ian on Reverse Side} <br /> I FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> Application Accepted 8y — Date <br /> Additional Comments: II <br /> I ' Phase tl Grout Inspectionoj q 111 Final Inspection �� <br /> I Inspection By 17 Date Inspection By ' Date <br /> I ' <br /> Fee Is Due:-❑ ANNUALLY I ❑ PER UNIT ❑ PER SITE <br /> ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> II <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> i�- DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> . PENALTY S <br /> OTHER II <br /> OTHER I� <br /> f <br /> Received by Date Receipt No. Permit No. <br /> idsuancd Date Mailed Delivered r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Bp■2009 STOCKTON,CA 95201. <br /> I�u <br />