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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApPilicauon. <br /> APPLICATION <br /> FOR OFFICE use: <br /> (For Non-Transferable, Revocable,Suspendable) . PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)" <br /> �. wli-VATERQUALITY <br /> Application is hereby made kothe anJoaquinLocalHealth District <br /> forapermittoconstructand/orinstalltheworkheremdescribed.Thisapplicationis <br /> made in compliance with San J��yOrdinance No.. 2 end the rules and reguVations of the San oaquin Locate ealtl}Districk. <br /> ICis ofth riExact Site Address k AY <br /> ,Eu'St 0/� �•S ,: '.c ,� E r Phone '� ,�s <br /> Owners Name City v4 ' <br /> Address _a <br /> r License# 3 Business Phone <br /> Contractor's Name .-�r <br /> � '.' •. Emergency Phone <br /> Contractor's Address J No <br /> Is Certificate of Workman's Compensation Insurance n File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑, RECONDITION[] DESTRUCTION <br /> WELL CHLORINATION C1WELL ABANDONMENT OTHER 11 � P P INSTALLATION❑ PUMP REPAIR❑ �1 <br /> REPLACEMENT❑ Pit Priv —r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> Other <br /> Sewage Disposal Field C� 'e- Cesspool/Seepage Pit � <br /> Property Line o?:5�' -i Private Domestic Well S)Le_ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE .❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC <br /> 13 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 13 CATHODIC PROTECTION El ROTARY Type of Grout N <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL' Surface Seal Installed By: <br /> t PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work one <br /> ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter fJ✓ _WI , <br /> Describe Material and Procedure- <br /> Describe <br /> C Cv <br /> I hereby certify that I have prepared this application and that the 4ork 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 pertormance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i I will ca for a Gr nspecti prior grouting and a final inspection. <br /> Title: ��' Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> 4PHASE 1 Date 7 <br /> Application Accepted'By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection ByDate Inspection By Date <br /> ❑ PERR <br /> 'UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received BY July 31 <br /> Fee IS Due: F-1 ANNUALLY <br /> BILLING REMITTANCE $ AMOUNT DUE 'CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED MOUNT <br /> FEE <br /> L7=s5 <br /> PRORATION ' <br /> PLUS <br /> a CCC S�ee <br /> PENALTY c <br /> OTHER <br /> OTHER <br /> 73 7 <br /> Received by <br /> Dat Receipt No. Permit No. ssuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO,. ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1$01 E.HAZELTON AVE.,P.O.Box 21)09 STOCKTON,CA 95207 <br />