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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The APPlication. A <br /> FOR OFFICE USE: APPLICATION < <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 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 /> 8¢ ' <br /> made in compliance with San Joaquin County Ordinance o. 1and the rules and regulations of the San Joaquin Local Health istrict. .y <br /> Exact Site Address 7 7 L�. II�� t N City/Town <br /> Owner's Name Phone . �`�S- 9 S10�o I <br /> Address A I City �,.�r� <br /> License# a29D V13 Business Phone_ �5 -/LA'S <br /> Contractor's Name � �I , <br /> ContractA"",Address ��� �` Ctl Emergency Phone <br /> Is Certificate of Workman's CompensationIn urance on File With SJL•HD? Yes— X No ; <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ pp,� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ + <br /> REPLACEMENT❑ ��} <br /> DISTANCE TO NEAREST: Septic Tank 70Sewer Lines Pit Privy <br /> Sewage Disposal Field 7tO >t' 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/PUBLIG ❑ DRIVEN Gauge of Casing 4 <br /> t � <br /> 11IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION XROTARY Type of Grout - <br /> ❑ DISPOSAL ❑ OTHER Other Information t -211 <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: 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 V <br /> f ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. v <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 /> f is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Caiifornia." <br /> l 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 Grout Inspection prior to grouting and a final inspection. <br /> { Signed X r �J Title: Date: <br /> (Dr�PtPlan on Reverse Side) Or <br /> FOR DEPARTMENT USE ONLY c �� <br /> I PHASE I � <br /> Application Accepted By Date 4\ <br /> Additional Comments: <br /> phase"II Oro spection Pha e I Final Inspection �� �, <br /> Inspection By a Date Inspection By Date _n <br /> ktp <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 4 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1111 REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> i OTHER <br /> OTHER <br /> ? <br /> Received 6y Dae Receipt No. Permit No. " Issuance Date Mailed Delivered <br /> APPLICANT— ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br /> -- <br />