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ApplicationsWillBeProcessedWhenSubmittedProperly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION- n <br /> (For Non-Transferable, Revocable, Suspendable) -D <br /> L ENVIRONMENTAL HEALTH PERMIT PUMP&WELL f <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application ishereb ad totheSan Joaquin ocalHealth Districtforapermit toconstruct and/or installtheworkherein described.This application is <br /> made in complian w" th iC <br /> n ounty rdmance No. 166 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addres � <br /> City/Town . �n <br /> T <br /> Owner's Name �.Q� �yiS is C a ' Phone <br /> Address .�7r S' l[) • a¢ i t k h1i = - City tool Q <br /> Contractor's Name C_K Ptd )A,& D o - License#3 S�ab3 Business PhoneL�_ '� l 7 <br /> Contractor's Address (}T �0 Emergency Phone .75-_I/3 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /DOr Sewer Lines Pit Privy ---4w <br /> Sewage Disposal f=ield Cesspool/Seepage Pit Other <br /> Property Line i7 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ /1 doom <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation r <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �I <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing A <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t J <br /> ❑ CATHODIC PROTECTION 19 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor C C <br /> Type of Pump 11-- H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 7 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �0�4 <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. <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 wilII for a Gr s ection prior to grouting and a final inspection. b <br /> Signed X /31 nIA NOA Al-AL Title: Date: <br /> (Draw Plot Pian on Reverse Side <br /> FOR EPARTM NT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> hese Grout Inspection +� Final Inspection gp <br /> Inspection By Date ~' 1 inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT " <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -71 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />