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J Applications WiiiaBe Processed'W„en Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OF!%CE USE: f. APPLICATION C' <br /> _ - (For Non-Transferable, Revocable, Suspendable) <br /> �;- - PUMP&WELL Q ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN'TRIPLICATE) WATER QUALITY ('�r <br /> E Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> F <br /> made in compliance with San San Joaquin County Ord�ifn nce No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> k Exact Site Address 1cE � City/Town <br /> r <br /> Owner's Name p C�-E1�e¢� Phone <br /> f Address k 4 ge7 City <br /> Contractor's Name License#29 Business Phone 2.3-1,/41/6 <br /> t Contractor's Address Ru”- � a T� ,.,-._ 336 Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L— No <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 /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r <br /> ❑ DISPOSAL ❑ OTHER Other Information 1 <br /> r ❑ GEOPHYSICAL Surface Seal Inst ed By: <br /> PUMP INSTALLATION: Contractor <br /> 1 0-41— 1 C <br /> Type of Pump_ H.P. <br /> w PUMP REPLACEMENT: {.❑ State Work Done <br /> PUMP REPAIR: IM State Work Done o <br /> DESTRUCTION OF WELL: F Well Diameter - Approximate Depth 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 /> Contractor's hiring or sub-contracting signature certifies the following:"i certify that in the performance of the woi for which this <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California." ( . 2!K <br /> I will 711 for a G Inspection prior to grouting and a final inspection. <br /> Signed )C +Date. �G <br /> - (Draw Plot Plan on Reverse Side) <br /> FOR DEPART ENT USE ONLY <br /> PHASEI � ' <br /> k Application Accepted By Date <br /> Additional Comments: <br /> ase it Grout Inspection Rha s III Final Inspection <br /> f <br /> Inspection By Date Inspection By Date <br /> s <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 /> BILLING REMITTANCE $ <br /> ' BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ( J AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> r PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Re ewed by D to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> ���,� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CAk95201 <br />