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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OM,110E USE: APPLICATION <br /> _. t <br /> (For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin Cou Ordinance N . 1862 and the rules and regulations of the San�oaqu' focal Health District. <br /> Exact Site Address 0 � City/.Town 4% { <br /> Owner's Name Phone '" � 3 Il <br /> Address U e. 0 City <br /> Contractor's Name License <br /> Business Phone_ <br /> Contractor's Address Q a.�''`'Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No 4 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RE=CONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ : - OTHER ❑ Y PUMP INSTALLATION 1$ PUMP REPAIR❑ <br /> REPLACEMENT❑ - / \J\ T <br /> DISTANCE TO NEARESTf Septic Tank Sewer Eines Pit Privy <br /> --- -•- - .Sewage-Disposal.Field---�—•�— �.Cesspaa)lSeepage Pit_ Other <br /> Property Lined Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL I' <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavatidn <br /> rf <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing " <br /> ❑ IRRIGATION F ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout '�3e_ o�i <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL_ Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ; Vi' H.P- <br /> PUMP REPLACEMENT:' ❑ State Work Done <br /> PUI(r1P REPAIR: ❑ State Work Done : <br /> DESTRUCTION OF WELL: Well Diameter {Approximate Depth <br /> y. <br /> Describe Material and Procedure - <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will'be done inkaccordance with Sa_n-Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health bistriict. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the perfoP{mance 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 Cal.iforrfla." <br /> s <br /> I wi ll or a Grout I . pection prior to grouting and a final inspe n. ; <br /> Signed X �!/`R1 ' d���tle: w�. ' ��-�•t r .Date: <br /> (Draw Plot Plan on Reverse de) ??}±±± <br /> FOR DEPARTMENT USE ONLY s i <br /> 1 <br /> PHASE l T y r ! t <br /> Application Accepted By t - `Dat rr. <br /> Additional Comments: is <br /> Phase II Grout Inspection I PhaO 11 anal nspec onlzb <br /> Inspection By Date Inspection B �e Dade <br /> G - <br /> V <br /> Fee is Dile:-❑ ANNUALLY ❑ PER UNIT 0 PER SITE ❑ EACH ❑ January 5 &ReCeived:ByJanuary 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE 'CHECKED <br /> DATE DATE. REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS y _ <br /> PENALTY <br /> OTHER / <br /> OTHER <br /> •Received by Date Receipt No. Permit No. suanceOafe Mailed Delivered. ✓ - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />