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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: w APPLICATION <br /> •- ,v (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> 3 , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> .R <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 60 City/Town <br /> Owner's Name ` Phone <br /> Address &IL[ 11. City—�lL � � <br /> Contractor's Name .:..License#--�Z�X/3 Business-Phone- <br /> Contractor's <br /> usiness•Phone Contractor's Address 474 'Emergency Phone, rf, t. I <br /> Is Certificate of Workman's Compensation I�ns•urance on.File With SJLHD? Yes No r n <br /> TYPE OF'WORK (CHECK): NEW WELLJ9 DEEPEN ❑- ' -RECONDITION❑ DESTRUCTION D '_' -_ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tarik ,T Sewer Lines S� 7`' Pit Privy <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. ❑hCABLE TOOL ' ---Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE__a 0 DRILLED I Dia. of Well Casing.... <br /> 9 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ;© IRRIGATION X GRAVEL PACK Depth of Grout Seal tT�J <br /> ❑^CATHODIC PROTECTION )<ROTARY Type of Grout <br /> .❑ DISPOSAL ❑ OTHER Other Information 2i <br /> .❑ GEOPHYSICAL Surface Seal Installed By:. 17 <br /> PUMP INSTALLATION: Contractor -� <br /> o <br /> -i`° Type of Pump <br /> REPLACEMENT:EPLACEMENT: �❑ State Work Done_ <br /> .w t,� <br /> PUMP REPAIR- ❑ State Work Done = "� <br /> DESTRUCTION OF WELL: Well Diameter Approximatebepth [ <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 JoaquinkCounty <br /> s ordinances, state laws, and rules and.regulations of the San Joaquin Local Health District. <br /> -Home owner licensed agent's signature certifies the following:"I certify that in the perfprmance of the work for which Athis permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Califor'nia." <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 /> I will call for a Grout lnsppclion prior to grouting and-a final inspection. <br /> Signed X __ Title. d e s Date: / } a <br /> 's (Dr lot Plan on Revere Side) !6 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i «.... <br /> Application Accepted.ByDate[o <br /> Additional Comments: a _ <br /> I out InspectionPhase I Final inspection i <br /> Inspection By Date. `////� .---Y'= v 'Inspection By M -` Date <br /> IL X Y' <br /> .Fee Is Due: ❑ ANNUALLY PER UNITc ❑ PER SITE ❑ EACH ❑. January 1 &Received By January 31 _"-�❑ J,yly 1`�&:,Received By July 31 <br /> BILLING REMITTANCE $ ° \` - '1 \ REMIT <br /> BASE EXPLANATION ` AMOUNT DUE,. CHECKED <br /> DATE DATE 1 REMITTED { AMOUNT <br /> M :! <br /> FEE <br /> LESS <br /> PRORATION "4 _ <br /> PLUS .. .� L €. rt , �. �'i ,�:� �`° `r •`tic�;# 4 `'!'(°- �r`i.\, ,. \.'a _ <br /> PENALTY <br /> OTHER.. - - _,q�-!; "'+,i,'. �,,��: - • } <br /> OTHER <br /> _ Received bycl <br /> te_ Receipt No Permit No. Issu nce Dae - Mailed - Delivered �- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> k <br />