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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL IV/ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance withJoaquin�nty Ordinance No. 1862 air d the rules qnd regi tion f the San Joaquin Local Health District. <br /> Exact Site Address 76 �/�U�.C-��✓ .¢_rG/. � it /Town <br /> Owner's Name 'G'' Phone <br /> Address City �i�/S� _FPA 9.1 .33<P <br /> Contractor's Name License# Business Phone I <br /> Contractor's Address aT,2,W,0 4,E57 , a ya Emergency Phone - !� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes 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 /> ❑ 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 t <br /> DESTRUCTION OF WELL: Well Diameter. Approximate Depth 't <br /> Describe,Material and Procedure / I e- <br /> 1 <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 rule## and regulations of the San Joaquin Local Health District. <br /> Homeowner 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 /> 0 '4 <br /> Contractor's hiring or sub-contracting signature certifies the following"I certify thatin the performance of the work for which this <br /> permit is issued, I shall em to �_�ns'_ __. <br /> p p yipersons stjbject to workman's compensation laws of California." <br /> I will for a Grout Inspec nor t routing and a final inspection. <br /> Signed X ' Title: ;f//�� `.P __ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (} )} �� 1LqL,� <br /> Application Accepted By - _�-�--'- ---- .... _----- Date__,. <br /> Additional Comments: <br /> Kase 11 Grout Inspection Pha III Final Inspection <br /> Inspection By � ��FS1 4�- Date�t�-`�T'GJ Inspection 8y Date <br /> %� -1 <br /> r <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 /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> z �8 s <br /> Received by D to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />