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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. w <br /> FOR OFFICE USE: APPLICATION <br /> - (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT P PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) r/"(+4 G_T� cr x��" WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address s• r {J 4lrScAII City/Town ! c <br /> y CA <br /> ' Owner's Name {�i�' Phone 'LL C Ua e1 r <br /> Address �� City r <br /> Contractor's Name g License#tea Business Phone - Own <br /> Contractor's Address Emergency Phone - I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes t• No <br /> TYPE OF WORK (CHECK); NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION Ia-- <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 b 0 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> t ❑ 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 <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: iI Q It <br /> � Well Diameter Approximate Depth 2,5- <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 /> r 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 /> 1 ill c I for Groui Insp ction prior to grou#ing and a final inspection. <br /> Signed X <br /> Title: 4:�(q r t:';it..cid Date: <br /> (Draw Plot Plan on Reverse Side) <br /> f Y <br /> pp FOR DEPARTMENT USE ONLY <br /> PHASE i 1��t <br /> Application Accepted By ,w�w,v5 Date <br /> Additional Comments: <br /> Phase II Grout Inspection P se III Fi Inspection <br /> Inspection By_ _ Date Inspection By Date f <br /> ll <br /> Fee Is Due: ❑.ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReceivedByJanuary 31 ❑ July 1 R Received By July 31 J <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED - <br /> AMOUNT I <br /> FEE f 3 <br /> LESS [ <br /> PRORATION - <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> OTHER <br /> Received by - p to Receipt o- Permit No Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES v1601 E..HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 <br />