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Appkations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br />{ (ForeNon-Tmnsfmble, 11%vocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Oistrictfora permit to construct and/or install the work herein described.This application ts�- <br /> made in compliance with San Joac uin Coun Ordinance No. 1862 and the rules and regul ions o the San oaquin Local Health District.,, <br /> Exact Site Address i* AO 24? � -^ <br /> Owner's NameG _ Phone <br /> Address City !�t <br /> f <br /> Contractor's NameLicense# _2960 Y73- Business Phone_,-_ I <br /> Contractor's Address I Emergency Phone � - 7� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ( No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ; <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> r DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> f Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line _ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL rr W <br /> r <br /> 11 yINDUSTRIAL 11 CABLE TOOL Dia, of Well Excavation <br /> — <br /> 0 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /160 WA -Cl <br /> ❑ IRRIGATION t�d GRAVEL PACK Depth of Grout Seal ISS <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done - <br /> 'DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> a <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 /> Home owner 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 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 wi I call for a Grout I ection pri r to grouting and a final inspection. <br /> I Signed X Date: <br /> /oZ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI Q <br /> Application Accepted By - Date�— `'80 '. <br /> Additional Comments: <br /> ase II Gr t Inspection iPjhase III Fi I Insp n <br /> �CJC� w <br /> Inspection By ate� - - So Inspection By to <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REM}TTED AMOUNT <br /> c,�r d © _ <br /> FEE 7� L-12 <br /> LESS <br /> PRORATION <br /> PLUS <br /> h PENALTY <br /> I OTHER <br /> OTHER <br /> !a, 6 561 �6 \S <br /> Received by Mate Receipt No. Permit No. Issuance Date Mailed - Delivered <br /> 5 APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />