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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ( ENVIRONMENTAL HEALTH PERMIT 4 <br /> (COMPLETE IN TRIPLICATE) .. C�����- `j� 7+0 • * 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 Joa In C�unit Ordinance and the rules and regulations of the San Joaquin oval He Ith District. <br /> Exact Site Address �Q)}f r" hr!"V., / -)!� t ru" �7-f City/Town r A? <br /> Owner's Name f ! Phone <br /> Address - �XA City /W4, <br /> eat <br /> Contractor's Name6e n// ** License#lf_A V ;lam Business Phone 'I�a �j <br /> 46 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File WW SJLHD? Yes TJX _ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPENO/ RECONDITION❑ DESTRUCTION Q� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® I <br /> REPLACEMENT❑ j <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 /> J9 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 77 LAR 0 H.P. l 1J <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done 731te �� ��ej Zr Q, <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 lows of California." <br /> Contractor's hiring or sub-contracting signature certifiesthe 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 wi call for/a Grout Inspection n r a groutin and.a:final Insp ction. <br /> Signed X f Ile: Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � 5 2 t <br /> Application Accepted By L.7 Date 6 1{l' <br /> Additional Comments: Aa <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 11 <br /> FEE <br /> LESS <br /> PRORATION — <br /> PLUS <br /> PENALTY �• — <br /> OTHER N 10 J/ <br /> OTHER �} / <br /> Off✓ � [ <br /> Received by Date Receipt No, Permit No. Iss ante ate Mailed ,Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 — <br />