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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> f ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY DIU <br /> I <br /> Appl ication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the k <br /> herein described.This application is <br /> made in compliance w1th San Joaquin Co my O inanc No. 1862 and the r es and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Q ` _ City/Town <br /> Owner's Na a L� doneIF <br /> Cv <br /> Address 20 _ City <br /> Contractor's Name Liceno <br /> �� Busin P ne l <br /> Contractor's Address Emergency Phone / <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL A—DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> .WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION `PUMP REPAIR❑ <br /> REPLACEMENT❑# <br /> DISTANCE TO NEAREST: Septic Tank &OA L�—:7- Sewer Lines Tl�e Pit Privy <br /> 1 ► Sewage Disposal Field .6!1r' Cesspool/Seepage Pit /VO4eP _ Other <br /> t Property Lined S/ Private Domestic Well��ublic Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> gi-TYUMESTIC/P141VATE ❑ DRILLED Dia. of Well Casing <br /> ❑.DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing 1. <br /> C1 IRRIGATION 11 GRAVEL PACK Depth of Grout Seal �\ <br /> ❑ CATHODIC PROTECTION NARY Type of Grout[ <br /> ❑ DISPOSAL ❑ OTHER Other information {' <br /> ❑ GEOPHYSICAL Surface Seal Installe 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 /> 1 hereby certify that have prepared thts applicaton`an�'ta� ,.wUrywill be lune N <br /> ordinances, state laws, and rules ffdr 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 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 c I for a Grout Inspection prior to grouti nd a final inspection. <br /> Signed X �zma.41 Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FORD �ARTMENT US LY <br /> PHASE I r <br /> Application Accepte B U Date <br /> Additional Comments' <br /> IV <br /> Phase II Grout Ins ction Ph f Final Insp tion <br /> Inspection Byl Date—��!, Y/ Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REWT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE dD <br /> LESS + <br /> r' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Vf 71 J9 ` <br /> 37�I-)->-57.. _ 1 1/�V -7� <br /> Received by Dale Receipt No. Permit No. Issuance Date Mailed Delivered -, <br /> APPLICANT—RETURN ALL COPIES TO:-_ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />