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- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f' FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT { <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY y ,� <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 Cgunty Ordinance No. 1862 a d the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_ .� City/Townes -- <br /> Owner's Name i^ b" 1/ L Phone <br /> Address F - City ,L i <br /> Contractor's Name A, P!•_ 6—nn iLff 16 �Gf- License# Business Phone r7 �3p <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on T=ile With SJLHD? Yes [� No <br /> TYPE OF WORK (CHECK): NEW WELL O DEEPEN ❑ RECONDITIOND- -DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ X <br /> DISTANCE TO NEAREST: Septic Tank _ 57 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line�5-f Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation /P1 <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE 9 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 0 <br /> f ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ C_,AhoN <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 4-m- G � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 5146 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 /> 6 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin-County �- <br /> L ordinances, state laws, and rules and regulations of the San Joaquin,Local Health District. - <br /> !. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit L <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:1 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 Gro t Inspect n pr' r to grouting and a final Title:inspection. i <br /> Signed X 1 A6 .- Dale: <br /> - Dale• <br /> (Draw Plot Plan on Reverse Side)" <br /> f FOR DEPARTMENT USE ONLY <br /> r - <br /> ti 'PHASE I a y <br /> Application Accepted By D/ Date I <br /> Additional Comments:. <br /> Ph e I Grout nspection r� Phase IH Final rection <br /> inspection By Date �` inspection By �f� Date �A <br /> t <br /> Fee Is Due: ❑ ANNUALL? ❑ PER UNIT ❑''PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 ❑'July 1 &Received By July 31 <br /> REMIT <br /> i <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> � AMOUNT <br /> FEE g RJ <br /> a <br /> LESS _ <br /> PRORATION <br /> PLUS x _ <br /> PENALTY <br /> OTHER <br /> OTHER - r - <br /> 1\1\ <br /> "Receivedby - Date Receipt No. s Permit No. Issuance Date Mailed Delivered _ <br /> "`APPLICANT—RETURN ALL COPIES TO: - -ENVIRONMENTAL HEALTH PERMITISERVICES ,__ 1601 E HAZELTON AVE:,P.9,Box 2009 STOCKTON,CA 95201 <br />