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ApplicationsWillBeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY f <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Eiala,loaquin County Ordina ce No. 1862 and the rules and regulations of the San Joaquin Local alth District. <br /> Exact Site Address 4 qn City/Town _S'o1�/��L � f <br /> Owner's Name S 54���1r IJ Phone <br /> Address S 14 4 ff City 57100W �! <br /> Contractor's Name License# Business Phone �+ <br /> r Contractor's Address �atyT� �� Emergency Phone t 1 <br /> Is Certificate of Workman's Compensation In�sur �on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL IS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ I <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines /QQ Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well I Public Domestic Well <br /> INTENDED USE �..x. - TYPE OF WELL <br /> ❑, IN STRIAL ❑ CABLE TOOL `•- Dia. of Well Excavation /d <br /> & DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing G f <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN { Gauge of Casing �Z <br /> ❑ IRRIGATION ❑ G5AJtEL PACK ..w.. Depth of Grout Seal drbr y <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL .Surface Seal installed By: <br /> PUMP INSTALLATION: �CiSntil n <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done' " <br /> PUMP REPAIR: ❑ State Work Done �- <br /> DESTRUCTION OF WELL: Well Diameter 941AppYoximate Depth <br /> ' i <br /> Describe Material and Proce$ure <br /> I hereby certify that I have prepared this application and that the wolill be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the Sail-Joaquin LOCdMHealth•fTIStrICt. <br /> Homeowner or licensed agent's signature certifies the following: l cartify.-that in the performance of:thework for which this permit <br /> is issued, I shall not employ any person in such manner as to becomAubject to workman's compensation laws of California." <br /> C actor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> kl ' <br /> t is issue hall em loy person subject to workman's compensation laws of California." <br /> call for Gro t In a ti #r 0 growl ing and a final inspec ' n. '' tt 4 I' <br /> Signed X Title: �C�"` (�(! c Date: 3 I V 5 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date 7 <br /> Additional Comments: <br /> Phase II Grout Inspection ,.-_c� Phase III Final Inspection <br /> Inspection By���i&.!2 date - Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PIER-51TE ❑ EACH, M❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31, <br /> 4b, REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION t AMOUNT DUE CHECKED <br /> DATE DATE REMITTED -ti. AMOUNT <br /> FEE .� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �- <br /> OTHER <br /> OTHER <br /> "-s <br /> -7-3/4-41 <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 />