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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .FOFi OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 Ordina ce No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> q� 7 b s^ City/Town <br /> Owner's Name ' y \ Phone e <br /> Address city Ac 60V\ ' ,�, _ <br /> Contractor's Name CYa Q,r a 5 5 Sh eV License#193,.� Business Phone -7 yai– j Y 7 <br /> Contractor's Addr�sia'a S�g �..�aw �51� C�a 'Emergency Phone i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes — No <br /> TYPE OF WORK (CHECK): NEW WELL M— DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION$ PUMP REPAIR❑ <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank /de��"ff=� Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other I <br /> Property Line7� Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL A <br /> ❑ INDUSTRIAL 9—C7ABLE TOOL Dia. of Well Excavation <br /> ❑ ESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> .DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> �RIGATiON ❑ 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, O <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done Q <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth m <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 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 call for a Grout Inspection prior to grouting and a final inspection. <br /> / <br /> Signed X Title: v] Date / 1s <br /> (Draw Plot Plan on Reverse Side) t <br /> FOR EPARTM T USE ONLY <br /> PHASE <br /> Application Accepted By C1 <br /> Date <br /> Additional Comments: A All <br /> Phase II Grout Inspection P a 1 inal Ins ions <br /> Inspection By Date Inspection By t/ e <br /> 17 <br /> Fee IS Due: ❑ ANNUALLY ElPER UNIT ER SITE ElEACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By Jufy 31 <br /> BILLING REMITTANCE $ FILWT <br /> BASE EXPLANATION AMOUNT DUECHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUSPENALTY O <br /> OTHER <br /> OTHER <br /> 7 l 4 0d <br /> Received by Dat Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />