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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joain County Ordinance No 1862 nd the rules and regulations of the San Joaquin Lo al Health District. <br /> Exact Site Address o� City/Town <br /> YOn� e� <br /> Owner's Name t sos) Phone " <br /> Address 7 9City N <br /> Contractor's Name W` License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 6' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR o6 <br /> REPLACEMENT❑ 1 ­3IUO f <br /> DISTANCE TO NEAREST: Septic Tank 100 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/$eepage Pit Other <br /> Property Line Private Domestic Well -,--S Public Domestic Well <br /> INTENDED USE TYPE OF WELL (f <br /> ❑ INDUSTRIAL &CABLE TOOL Dia. of Well Excavation <br /> c <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5 a <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 5 �9r`i /M Y, <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: J <br /> PUMP INSTALLATION: Contractor .Cly <br /> Type of Pump H.P. a; <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done O <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 /> 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 work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call fpr Grout Ins ecilion p or grouting and a final inspectionrr�, � ,�,�_ /- <br /> Signed X c Title: C� Date: tigo ` <br /> (Draw Plot Plan on Reverse Side) <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date � <br /> Additional Comments: <br /> Phase 11 Grout Inspection o C� Phase III Final Inspection <br /> Inspection By ate o `o U _ Inspection By K//A Date <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JlWy 31 t <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED y <br /> r /y AMOUNT ] <br /> FEE ti..J .� *Cf 3 <br /> LESS <br /> PRORATION 00000, <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 66psc G b <br /> Received by - Date Receipt No. Permit No. r Rs-suancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />