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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE $E: APPLICATION / <br /> (For Nan-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermit toconstructand/or installthework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance N 1862 and the r les and regulations of the San Joaquin Local Health District. <br /> Exact Site Address / �. City/Town ��,C f D N <br /> Owner's Name F'. /J Phone Vag --2.50 <br /> / <br /> Address City <br /> Contractor's Name o' icense#& �/!� Business Phone <br /> Contractor's Address ya Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL"ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 1 <br /> REPLACEMENT❑ i f <br /> DISTANCE TO NEAREST: Septic Tank Sewer'Lines 106 f Pit Privy V <br /> Sewage Disposal Field /or) I# Cesspool/Seepage Pit Other <br /> Property Line 16 `4_ Private Domestic Well/0 -f Public Domestic Well <br /> INTENDED USE TYPE OF WELL �t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 b <br /> rk DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Vd <br /> ❑ IRRIGATION ral GRAVEL PACK Depth of Grout Seal �U <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout C -,uf <br /> ❑ DISPOSAL OTHER Other Information m <br /> 11 GEOPHYSICAL Surface Seal Installed By: _Qok/l r2 "Y <br /> PUMP INSTALLATION: Contractor .� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 0:State Work Done <br /> PUMP REPAIR: ❑I State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth tl t <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, G <br /> Homeowner 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 /> C/S.* <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this m <br /> permit is issued, I shall employ ZrIor <br /> sons subject to workman's compensation laws of California." <br /> I all for1a rou spe o to grouting and a final Inspection. <br /> Signed X sTitle. —,LQ r.v . Date: 2_0 , <br /> (Draw Plot.Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted!BY- �' ---- - Date <br /> Additional Comments: _ <br /> P e I Grout Inspection �h se II Final Inspection <br /> (� —Z 0 <br /> Inspection By Dates - - Inspection By <br /> DatOfl <br /> Fee Is Due: ❑-ANNUALLY ❑ PER UNIT '-❑ PER SITE ❑ EACH- ❑ January 1 &Received By January'31 - ❑ July 1 8,Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ ; <br /> BASE EXPLANATION AMOUNT AVE CHECKED <br /> DATE DATE REMITTED - <br /> AMOUNT <br /> FEE <br /> -LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> _ r <br /> OTHER - <br /> � <br /> Received by Date Receipt No. Permit No. - Issuance Date, Mailed Delivered F <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 9520 <br />