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Applications WillBeProcessedWhen SubmittedProperlycompletea. Besure tosign 1ne,application. <br /> BICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> 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 w San J uin Count ance No. 1862 and the rules and regulations of the San Joa ocal Health District. <br /> Exact Site Address 1=R �mg� _ City/Town <br /> L <br /> Owner's Nam Phone <br /> Address / ,�c� City +� <br /> Contractor's Name License t(/Tf/� jj,Q Business hone <br /> Contractor's Address WEmergency Phone <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 /> 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> }I i <br /> DOMESTIC/PRIVATE IFILDRILLED Dia. of Well Casing <br /> 11DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �V_r� P ✓ - <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal �G <br /> ❑ CATHODIC PROTECTION ROTARY Type of Groutt...7— <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> V <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done r n <br /> DESTRUCTION OF WELL: Well Diameter- �1 t 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 9 , <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 will <br /> call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X t!> f%' 6071d 04 -V _- Title: Lr Date:-- 1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> Application Accepted y Dat 7 f <br /> Additional Comment : <br /> Fhffbe 11 Grout InspectionG} • a inal Inspectio <br /> Inspection 8y Date �8-t� { Inspectio y Dat <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑,January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> lfld�0 <br /> Received by Date Receipt No. Permit No. I Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95101 <br />