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} r� Applications Will [fie Processed When Submitted ProperlyComplete . ,. <br /> i APPLICATION <br /> FOR OFF1 USE: V <br /> 4 (For Non-Transferable, Revocable,Suspendahle) <br /> PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY plication is <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work,herein described.This ap \� <br /> made in compliance with 5 n Joa uin ouRty Or finance N 1852 and the rules and re ulatCiQ�n�.pf the�a� Jgagtli� oca e 1thi�ct. <br /> �_ V� <br /> Exact Site Address-1_1- "c l[[Cy��/7o n d [� <br /> Phone a }" <br /> Owner's Name <br /> Address City - <br /> Contractor's Name License 0 Business Phone <br /> -r - ivy - e <br /> ' Contractor's Address Emergency Phon� r <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ O <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ '.� <br /> DISTANCE TO NEAREST: Septic Tank r Sewer Lines ® f, —Pitt Privy_ <br /> -� -� - Sewage Disposal-Field Cesspool/Seepage Pit Other— <br /> 'Property <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 /> 19 IRRIGATION ❑ GRAVEL PACK = Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION O ROTARY Type of Grout A <br /> j <br /> 11 OTHER Other Information 13 DISPOSAL .. Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor } <br /> t Type of Pump.. H.P. <br /> PUMP REPLACEMENT- ❑ State Work Done <br /> PUMP REPAIR- _ ❑ State Work Done <br /> - f Approximate Depth <br /> t DESTRUCTION OF WELL: Well Diameter - <br /> r 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 tiles 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•a`s 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 work forwhichthis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> II for a Grout Insp rt In pr to uting and a final inspection. <br /> Signed X. <br /> Title: Date: i <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE l Date <br /> Application Accepted By - <br /> Additional Comments: ` , <br /> Phase 111 Final Inspection <br /> Phase 11 Grout Inspection <br /> Inspection By atel-C/-1 Inspection By Date <br /> J ' <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE / ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE—% DATE REMITTED AMOUNT <br /> FEE <br /> f <br /> a LESS <br /> PRORATVON <br /> PLUS <br /> PENALTY <br /> OTHER [ <br /> OTHER , <br /> L' <br /> Issuance Date Mailed Delivered <br /> Received by Date Receipt No. Permit No. <br /> SSS1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES � <br />