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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign ThApplication. <br /> FOR OFFICE USE: APPLICATION �. <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �U l <br /> G 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 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address jl�� '-a 5--0 LSV -c¢,`, City/Town <br /> Owner's Name +ct✓ Phone <br /> Address �I City _ <br /> Contractor's Name t License#33-22'i"Y 7 ft Business Phone r <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes No rte" <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION6-`� PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other , <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ I>DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation I <br /> Aa 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 ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 7"`� �J <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Donelf <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. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 or a Grout I spection prior to grouting and a final inspection. <br /> Q <br /> Signed X Title: Date: L 1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 2, _ <br /> Application Accepted By � Dale <br /> Additional Comments: <br /> Phase II Grout Inspection hase III at Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REWTTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE cXr <br /> LESS �] <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received 6y Date Receipt No Perini[No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 „ <br />