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Applications Will Be Processed When Submitted Properly Comple4ed. Be Sure To Sign The Application. <br /> F0Pa OFFICE USE: APPLICATION <br /> A 4411 <br /> � (For Non-Transferable, Revocable,Slisp]endable) <br /> f� ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> 4 <br /> 5- �1 .q <br /> (COMPLETE IN TRIPLICATE) �` $',3 , ;,�.(a�¢:�=p,2 WATER QUALITY <br /> Appl ication is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is f <br /> made in compliance with San Joaquin C my Ordinance No. 62 and the rules and regulations of the San Joauin. Local Health District. <br /> Exact Site Address "—S City/Town { <br /> Owner's Name Pill.)• Si. LI 1 Li CL P_� Phone XVI �! <br /> Address _ �iJ_ . B`y C a- 441901 City <br /> Contractor's Name r License# Z I I 211�!Busii Phone J� <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❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION I& PUMP REPAIR❑ <br /> REPLACEMENT❑ s <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Weil Excavation A Pi <br /> ,`DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Qli <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing {N <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I <br /> I � <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout @•� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ,x <br /> PUMP INSTALLATION: Contractor r &A,ll # <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP-REPAIR:, ❑ State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter sApproximate 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 /> Homeowner 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r <br /> I wi call for a Grout Inspection prior Muting a a final inspection. I <br /> Signed X r . le: __`�� Date: } <br /> ff (Draw Plot P in on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 7 <br /> Application Accepted ByDate Z �� <br /> Additional Comments: � <br /> Phas II Grout Inspection Phas I I Final Inspection1 <br /> Inspection By' Date Inspection By ate <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION D '`MOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS- <br /> PRORATION <br /> PLUS • <br /> PENALTY i <br /> OTHER <br /> OTHER <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 />