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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. d" <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is # <br /> made in compliance witD.San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. E <br /> Exact Site Address + IS �d-� d - City/Town iLO j <br /> Owner's Name C'JC� I Phone <br /> Address a v ftit City <br /> Contractor's Name L L4qffLicense# 37 Rusin s Phone <br /> Contractor's Address Z►��. Emergency Phon <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD?. Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN El- RECOl�IDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL AB NDONMENT ❑ OTHER l] PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 1. Pit Privy ? <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well I <br /> INTENDED USE TYPE OF WELL d <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation — <br /> K DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing G <br /> ❑ DOMESTIC/PUBLIC El DRIVEN Gauge of Casing k. <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal sd l <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> ❑ 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 v a <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedute <br /> I hereby certify that I have prepared this application and thafithe 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 s ued, I shall not employ any person in such manner as to Ibecome subject to workman's compensation laws of California." <br /> nt aclor's hir' or sub tractin ignature certifies the following:"I certify that in the performance of the work forwhich this <br /> p rm is issue , I hall I y pers s subject to workman's compensation laws of California." <br /> I w all for a r In p ti n prio o grouting and a final ins ecti <br /> Signed X Title:, Date: <br /> (Draw Plot Plan on,Reverse Side) <br /> _ 3 <br /> FOR DEPARTMENT USE ONLY <br /> • I <br /> PHASE I <br /> Application Accepted By <br /> Additional Comments: _ <br /> tGr pection Phase III Final Inspectioninspection ByDate � v Inspection By <br /> Fee Is Due: ❑-ANNUALLY © PER UNIT'- ❑ PER SITE ❑ EACH' ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> REMIT <br /> 13ILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> �� O <br />' FEE <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> OTHER - it <br /> OTHER <br /> Received i)y. Date Receipt No Permit No. &uande Date Mailed Delivered - <br /> P.O.Box 2004 STOCKTON,CA 95201 <br /> - <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AYE., <br />