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4° Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheApplication. <br /> [FOR CIFFICE_,USE: APPLICATION <br /> r (For Non-Transferable, Revocable, Suspendable) 46 PUMP&WELL <br /> ar <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 1� �r$$�pp <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herefn des± rib�e�d,,+.Thi Z�pp lon.is <br /> made in compliance with San i Joaquin County Ordinance No. 1862 an the rules and regulations of the San J uin Local Healthtrict. © a T <br /> Exact Site Address City/Town 1 <br /> Owner's Name f Phone <br /> Address City <br /> Contractor's Name / License# � �-�L Business Phone_ ''y <br /> Contractor's Address 45©13 CS V Emergency Phone <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? -Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ElRECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ '5D 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines csD r_ — Pit Privy <br /> Sewage Disposal Meld r � Cesspool/seepage Pit Other <br /> Property Line Private Domestic Well_ � I Public Domestic Well <br /> INTENDED USE TYPE OF WELL /2 fi <br /> 13 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation _ f+' <br /> N <br /> X DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ( ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 1�10i <br /> ❑ CATHODIC PROTECTION KROTARY 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 <br /> DESTRUCTION OF WELL: j 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. �p <br /> O <br /> Home owner or licensed agentr '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 work forwhich this <br /> permit is issued, I shall employ per ons subject to workman's compensation laws of California." <br /> I will ca or a Gro t In cti rior to grouting and a final inspection. <br /> Signed X _ Title: Dale: c <br /> ��L — fS <br /> (Draw Plot Plan on Reverse de) <br /> LDEP RTMENT USE EONLYPHASEI Date 4'rApplication Accepted By <br /> Additional Comments: <br /> ,phase If G ut Inspection Phase 1111 Final Inspection <br /> nins p cti n By Date l '~7i ~� inspection By2ved <br /> - Date -- <br /> Fee Is Due ANNUALLY PER UNIT PER SITE El EACH ❑ January 1 &RecByJanuary 31 ❑ July 1 &Received By July 31 <br /> l REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> a DATE DATE REMITTED AMOUNT <br /> FEE � !/ <br /> LESS i} <br /> PRORATION I <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER # <br /> r11 <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 />