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Applications Will Be Processed When Submitted Prpperly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, hevocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY w, <br /> Application is hereby madetotheSaaLoc1r1;4AalthDistrictforapermittoconstructand/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and their les and regulations of the San Joaq n Lo ;Health District. <br /> OF <br /> City/Town 0J d9a <br /> Exact Site Address" <br /> 4 <br /> Owner's Name Phone pa <br /> City. <br /> Address �1 k. d s + <br /> Contractor's Name License#l�ttl 9i�s1--. Business Phone L <br /> Contractor's Address q5A Erhergency Phone O <br /> Is Certificate of Workman's Compensation Insurance on File ith SJ LH D? Yes 1r No V 1 <br /> TYPE OF'WORK (CHECK): NEW WELL 0` DEEPEN ❑ -RECONDITIONDESTRUCTION❑ - C7 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT E3OTHER P PUMP INSTALLATION® PUMP REPAIR❑ I <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines' Pit Privy <br /> Cesspool/See a e Pit Other { <br /> Sewage Disposal Field _ - P g <br /> Y Property Line Private Domestic Well R Public Domestic Well <br /> INTENDED USE <br /> TYPE OF WELL <br /> I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 15 DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing <br /> ❑ DRIVEN Garage of Casing <br /> yI <br /> ❑ TIC/PUBLIC <br /> I <br /> DOMES , <br /> ❑ IRRIGATION 1:1GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information F <br /> 11 GEOPHYSICAL / I Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> D <br /> Type of Pump .�'e H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work'Done <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 /> vf� Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 0 <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 /> � 4 <br /> 1 ill tali for a Grout I p c o o groutin nd a final''inspecti n.. <br /> Ya` Date:' <br /> Signed Title: .. <br /> (Draw lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i Date���y <br /> Application Accepted By <br /> Additional Cbmments: <br /> Phase II Grout Inspection d III i 1 Inspection f <br /> Inspection By Date Inspection ByXtse <br /> % <br /> [l t <br /> Fee Is Due: C1ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH" ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> t; a,; REMIT <br /> BILLING REMITTANCE _ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE iDATE "REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER J� <br /> i <br /> Received by Date <br /> Receipt No. Permit No. ssuance D to Mailed. Delivered <br /> E ._ P �t - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />