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1 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: f . APPLICATION ®J� <br /> l6 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY, <br /> Application is hereby made to the San 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.1862 and the rules and regulations of the San Joaquin oc l Health District. <br /> Exact Site Address S City/Town ` <br /> "/� <br /> Phone' <br /> / 6 <br /> Owner's Name '. <br /> Address '— Aakt'�G7 .- r. :�' City. <br /> Contractor's Name ��� License#1� 1 ��Business Phone 3- - 6 7 6 <br /> Contractor's Address <br /> t Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER El PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> tt DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy d t* <br /> f Sewage Disposal Field Cesspool/Seepage Pit Other_ Ohl <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL I <br /> 11 INDUSTRIAL 13CABLE TOOL Dia. of Well Excavation <br /> 9. DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> 1:1 DRIVEN Gauge of Casing ' <br /> r I <br /> 11 IRRIGATION �, E] 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 <br /> Type of Pump ✓ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 0 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 /> i ordinances, slate 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 forwhich 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 /> t to workman's compensation laws of California." <br /> permit is issued, I shall employ persons subjec <br /> II'will call for a Grout Insp do r r to gr ting,and final inspection. - <br /> Signed itle: ��� 4 Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR 9EPARTM ENT.USE ONLY <br /> PHASE I t (� Date tib L <br /> f Application Accepted y <br /> Additional Comme2l. <br /> Phase I Grout Inspection ' ` Phase III Final Inspection <br /> Inspection By Jai �` A Dake Inspection By �`'''" �' Date - Y <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> _ k BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE - 'EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE '•� . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Dekivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Baa 2009 STOCKTON,CA 95205 <br />