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Applications Will Be Processed When Submitted Properly Gompletea. tiesure Iosign IneMpplroanun. <br /> FOR OFFICE USE: / APPLICATION <br /> ,/',o L/(? /*vG (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> I ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This applicatbq <br /> ion isA <br /> ! <br /> made in compliance with San Joaquin County Ordi ante No.1862 and the s and gulations of the San Joaqui Loc i ealth s ct. <br /> Exact Site Address City/Town � G <br /> Owner's Name <br /> Phone <br /> Address 0I,� i �e,r 1 e.r City ae <br /> Contractor's Name a License# L —Zkf Business Phone____$41. L G' <br /> Contractor's Address �FlleWith <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation insurancID. YesNo <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ N <br /> REPLACEMENT❑ �l <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 /> r <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation i <br /> JR DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing I <br /> 13DOMESTIC/PUBLIC 1:1 DRIVEN Gauge of Casing s <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 S fr / + <br /> Type of Pump S � H.P, <br /> PUMP REPLACEMENT: ❑ State Work Done 4 11 1 11 <br /> �v <br /> PUMP REfflrfR: 95 State Work Done <br /> 111:1111011 <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 /> 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 /> Contractor's hiring or sub-contracting signature certifies the fallowing:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will call)for a Grout Ins c 'o or to r uting a final inspection. <br /> Signed + Title: /" Date: <br /> (Draw t Plan on Reverse Side) <br /> FORD PART NT USE ONLY <br /> PHASE 1 79 <br /> Application Accepted By Date l <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pha a 111 Final Inspection <br /> Inspection By Date ., Inspection 8 Date — 6'� <br /> Fee Is Due: ❑ ANNUALLY [3 PER UNIT 29 PER SITE 11 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 /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER tt } <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />