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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) 0 1 <br /> "t. 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 Jo um County Ordinance No. 1862 and the ru es a�1d a ulan <br /> tios of the San J aquin Loc Health District. <br /> Exact Site Address 0 F7—i City/Town o <br /> Owner's Name LC kgeA Phone —2- <br /> Address city_s ha_Cy <br /> Contractor's Name pr License # D4 24"t_ Business Phone <br /> Contractor's Address (4Emergency Phone 62 17Z r - <br /> Is Certificate of Workman's Compensations nce on File With SJLHD? Yes No . <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ L ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer LinesPit Privy <br /> Sewage Disposal Field 10i, a Cesspool/Seepage Pit Other__ i <br /> Property Line_.._— Private Domestic Well Public Domestic Well <br /> INTENDED USE 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 O <br /> O I <br /> ❑ IRRIGATION.' RAVEL-PACK Depth of Grout Seal <br /> 11CATHODIC PROTECTION ROTAR F Type of Grout 17,=e 1 <br /> ❑ DISPOSAL OTHER r Other Information <br /> ❑ GEOPHYSICAL " _ Surface Seal Installed By: C/4,9.0qr_ <br /> PUMP INSTALLATION: f Contractor <br /> b `Type of Pump 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 1 <br /> I hereby certify that I have prepared this applicatiA 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 At for a Grout In=tlonprloruting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Ak, Date <br /> Additional Comments: <br /> Phasefi Grout ection / Ph a 11 Final spection / <br /> Inspection By ate �8� Inspection By Dater f <br /> r <br /> Fee IS Due: ❑ ANNUALLY [] PER UNIT ❑ PER SITE ❑ EACH ❑ January Y &Received By January 31//El July 1 &Received.By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 7 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> 4,1- <br /> Received by Date Receipt No. Permit No. &uanc&Date Mailed Delivered <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />