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�ic (iorisWii�BeProcessedft� Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: e f� APPLICATION <br /> JULt} 8�For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ' �,�y� IRONMENTAL HEALTH PERMIT <br /> ��$� .���':.��$�' $.,.l7C�H�4. WATER QUALITY ,. <br /> (COMPLETE IN TRIPLICA ��L"�$j DISTRICT .,i_-' .,� , €�1 t. <br /> Application is hereby made to a an Joaquin Local Health District for a permit to construct and/or install thework herein described.This application is <br /> made in compliance_ with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Jioaquini>Local Health District. <br /> �> Cit /Town � <br /> Exact Site Address l <br /> City <br /> /Town <br /> Owner's`Name � �G�a-, <br /> r. � ( City 5.7� <br /> Address <br /> Contractor's Name E E' ^' License# moi 4d11��°Business Phone <br /> Contractor's Address Emergency Phone p.. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�� No <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 oCesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL l r <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 ` t <br /> ❑ DISPOSAL 13 OTHER <br /> Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ! <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth G <br /> r - 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 /> I <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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich 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 /> Signed X Title: Date: 7-2 -Z?- <br /> raw <br /> Zzraw Plot.Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 4 n-� <br /> Application Accepted By Date <br /> Additional Comments. <br /> Phase 11 Grout Inspection Ph 111 Final Inspection <br /> Inspection By--- A Date Inspection Date <br /> Fee 15 Due: 11 ANNUALLY 3—❑{ <br /> PER UNIT ❑ PER SITE ❑ EACH ❑ January.1 &Received By January 31 -13 July 1 8,Received By July 31 <br /> REMIT <br /> BILLING -,- REMITTANCE. - $ AMOUNT DUE CHECKED <br /> BASE 'EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER y is <br /> fleceived by Dat - - Receipt Noi- - - Perm4 No--` Issuance Date -Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />