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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. / <br /> FOR 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 Ordinance No.1862 and the rules and regulations of the San Joaqu)n Loc I Health District. <br /> Exact Site Address 4/ e 0i A City/Town +�OA+e rer <br /> Owner's Name Phone +� <br /> Address �7 *. y <br /> Contractor's Name c License#L�93T 7yS Business Phone d a- -76 7­4 I <br /> Contractor's AddressCP-J>A AV 1A= es Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes X No S)' <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 Lined Private Domestic Well Public Domestic Well <br /> INTENDED USE If TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installs y: <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ! <br /> PUMP REPAIR: ®. State Work Done ,1A&-z1Vfir &� <br /> DESTRUCTION OF WELL: Well Diameter �""""�"�"^�� —Approximate Depth - <br /> Describe Material and Procedure <br /> r <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit f <br /> is issued, I shall not employ anyiperson 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 /> k <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." + <br /> I will calf for a Grout Inspecort ^ro 'ng and., final inspection. - <br /> Signed F hie: / Date: <br /> (Draw Plo Ian on Reverse Side) f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I C, e <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final I spection <br /> Inspection By Date _ Inspection Eva Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT f <br /> BASE', EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED �€ <br /> AMOUNT I'4 <br /> FEE u <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> T <br /> .OTHER I r <br /> 1 <br /> Received by Date Receipt No. Permit No. - Issua ce 0a a Mailed - Delivered r <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 r <br />