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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> ( 1p440k (For Non-Transferable, Revocable,Suspendable) PUMP&WELL / <br /> -T ENVIRONMENTAL HEALTH PERMIT V <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Coun Ordinanc No.1862 and the rules and regulations of the San Joaq,u�in//l-�ocal af�Ith District. <br /> Exact Site Address <br /> es� n�Q 3Gu G� e City/Town <br /> Owner's Name `3 0 e G� alt ♦r Phone <br /> Address — �a IVG C-4, 40 City <br /> Contractor's Name Ip a► License# LN3-7�S Business Phoned <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on F'a With SJLHD? Yes No J <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 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <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 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor S el Amt • !J __ <br /> Type of Pump H.P, 1 <br /> PUMP REPLACEMENT: State Work Done .�J/r T.k11� d-- �IcSJ iC��ue�,ri7�✓ f►� 49 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w' call for a Grout Inspection pri to ro Ing nd a 'nal inspe n. <br /> 77 Signed �� te: A r Date: <br /> (Draw Plotneon Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE � �� <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection P se III Ft al Inspection p� <br /> Inspection 8y Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ElEACH ElJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �r AMOUNT <br /> FEE yP <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER (� Q <br /> T f <br /> Received by Date Receipt No. Permit No. 1S.U.11ab 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 />