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nsWillBeProcessed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> FOR r7F10E USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to theSan 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 Ordinance No. 1862nd the rules and r gulations of the an Joaquin Locaf Health District. <br /> t Exact Site Address-MQ6 <br /> Owner's Name <br /> Address Phone — <br /> Contractor's Name City 4 <br /> License It�QQ_�/,� Business Phone- <br /> Contractor's <br /> Address Emergency Phone62:�/5'—Qa7 f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? <br /> Yes. No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ <br /> REPLACEMENT PUMP REPAIR❑ <br /> ❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field11 <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic WellPublic Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation H <br /> DOMESTIC/PRIVATE ❑ DRILLEDn p✓�. <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Dia, of Well Casing <br /> ❑ IRRIGATION Gauge of Casing <br /> GRAVEL PACK Depth of Grout Seal f g' <br /> ❑ CATHODIC PROTECTION ROTARY —b <br /> DISPOSAL � TYPE of Grout_ a�a�,(- <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PU14 P INSTALLATION: ContractorI <br /> 4 Y <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ Stafe Work Done <br /> DESTRUCTION OF WELL: <br /> 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 /> Homeowner or licensed agent's signature certifies the fallowing:"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 sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: <br /> Date: 42 a <br /> raw Plot Plan on Reverse Side) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY 5 <br /> Application Accepted By } _Q <br /> Additional Comments: <br /> e It Grout pection se III Fina nspe n <br /> Inspection 8y - ate _ <br /> U Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING RFMITTANCEREWT' <br /> DATE REMITTED <br /> DATE $ AMOUNT DUE CHECKED <br /> I, <br /> FEE AMOUNT <br /> �} 7� a <br /> LESS 3 I <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S� � <br /> Received by Date Receipt No. Permit No. <br /> . - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ' <br /> 1601 E.HAZELTON AVE„P.O.Box 2009 STOCKTON,CA 95201 <br />