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4 <br /> Applications Will Be Processed When Submitted Properly Completed. aSureTo sign TneApplicativiri. , <br /> FOR OFFICE USE: ## APPLICATION <br /> 1 (Far Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> 111 ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is <br /> made in Compliance with San Jo ►lin County O inance,No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /jU -�-� _ City/Town <br /> Owner's Nye � Phone <br /> Address City <br /> Contractor's Name 147- License Business Phone <br /> Contractor's Address Emergency Phone j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X — No <br /> TYPE OF WORK (CHECK): NEW WELL DO DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ ` <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Priv <br /> r <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Well 4 <br /> INTENDED USE TYPE OF WELL / (� <br /> ❑ INDUSTRIAL r❑ CABLE TOOL Dia. of Well Excavation r <br /> 10 DOMESTIC/PRIVATE DRILLED Dia. of Well Casing G <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ® GRAVEL PACK Depth of Grout Seal , v{ I <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout �n-,wt�T <br /> ElDISPOSAL OTHER Other Information J <br /> ❑ GEOPHYSICAL I Surface Seal Installed By: <br /> 2K e Z7 <br /> PUMP INSTALLATION: Contractor <br /> iType of Pump to H.P. <br /> Q PUMP REPLACEMENT: 10 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 I hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 4 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I� 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 call for a�rou, �Pection prior to grouting and a final inspection. <br /> 1.Signed X t_ P1"�t ( Title: _ __ ops Date: <br /> 1 (Draw Plot Plan on Reverse Side) <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I � Date C� <br /> Application Accepted By <br /> Additional Comments: I <br /> Phase fll Final Inspection l� j`s <br /> j P ase 11 Grout Inspection <br /> fk inspection By L Date d�TA6P Inspection By r Date <br /> Fee IS DUE: ElANNUALLY ❑ PE,R1 UNIT El PER SITE El EACH C1 January 1 &Received By January 31 July 1 &Receiv d By REMITu1y 31 <br /> BASE I EXPLANAT40N BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> ( 43< <br /> k LESS <br /> ` PRORATiON <br /> PLUS <br /> PENALTY <br /> f OTHER <br /> OTHER <br /> I <br /> Date Receipt No. <br /> Received by <br /> Permit No. Issuance Date Mailed Delivered <br /> A <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 452 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 0,1 <br />